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SAN JOAOUIN COUNTY PUBLIC HEA&41y SERVICES ENVIRONMENTAL HEALTH OIVISIOIw-tt?r�� P.O. BOX S88, 304 EAST WEBER'AVENUE, STOCF�FW-'ICA-95201388 (209i 4W3429 I { NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OATE1SS�t[t (CEmpl/b in T►Ip6oBte) i APPUlCATK?N HI HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PEF"T TO CONSTRUCT ANMOR INSTALL THE WOWC DESCUSSEO. 7 N U'ADE IN cpm O WWI MN JOAMPH COUNTY DEVELOPMENT TRLE.CHAPTER B•1110,3 AND TW STANDARDS OF SAN JDAQUIN COUNTY PUBLIC HEALTH SERVICES,FN �NE ALTH OI�l�� JOB ADDREBBIOR APL/ !/�n�d to CITY ,a f�?LOT 117E _o OWNER'S NAME�•�'D LL✓1 C-. Jl'1`'i - ADDRESS i�•►-Y'Tlr l 1'HOHE ��.� , CONTRACTOR. C'_ �lC ADDRESS1 ]--1�i�5i `tel:a 1�1�*^ �\�� LIC/ r �i T.St PHONE_ �/. 1 BUS CONTRACTOR ADDRESS_ LIC/ PHOM_ TYPE OF 801DC WORK: NEW INSTALLATION ❑ REPAIRJADDITION ❑ DESTRUCTION ❑ WO PEPTIC SYSTEM PERMITTED:F PUBLIC SEWER IS AVAK.AOLE WITHIN TOO FFFT OF SUR.DINO.I PPRC TEST(C 1 1 HOW MANY APp1IeS11on/ INSTALLATION WILL SERVE: RESIDENCE PI COMMFRCIAL ❑ OTHER ❑ NUPMER OF LMNO UNITS:, W..WREPS OF BEDROOMS: Ll NUMBER OF MAPLOYEEA- 'p CHARACTER OF SOIL TO A DEPTH OF 3 FEET: f 24'y P116UMP SOIL.CHARACTER: L2JY WATFR TABLE DEPTH SU�TIC TANKK/1EASE TRAP ❑TYpf,TAFO CAPACrTY NO.COMPARTMENT'] PRO T16ATIAMT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION P 0PERTY UNE" �.. LIFT STATION❑ 817.E tYFE OF PUMP SAND OIL 6FPARATOR IENCLOSEO SY6TEMI LEACHING UNE ❑ NO.S LENGTH OF LMJFR DISTANCE TO NEAREST:WELL FOUNDATIONS PROPERTY LSJE �y FILTER BED ❑WROTH LENGTH, DEPTH DISTANCE 10 NEARFEIT:WELL FOUNDATI'JN PROPERTY LUNE L MOLMDED L❑�WtDTH LENGTH DEPTH OrSTANCF TO NEAREST:WELLFOUND/.TION PROPERTY LME •+- SE,EPAOE PITS p DEPTH -A SIZE �L� NUMBER _DISTANCE 1 O NEAFTEIT:WELL j_ ,�FOUNDATION J U /PROPERTY NE 5 U 8UUM6 ❑WROTH LENGTH _DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERI"`/UNE OISPOSAL PONDS ❑1MDIH LFNGTH _DEPIH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINES J HERESY CERTIFY THAT I HAVE PRFPARED THIO APPLICATION AND TIIAT THE 1VOHIL WILL OF TONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES ANO OTATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAGUIN COUNTY.HOME OWNER OR LR.ENSFD AGENT'S SIGNATURE CERTIFR:R THE FOLLOWING!•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHK:H THIS Pf RNR IR 19SUED,I SHALL NOT EMPLOV ANY PERSON M SUCH A MANNER AS TO BECOME RIJIUECT TO WORKMAN'S COMPENSATION LAWS OP CALIFOIMJIA,' CONTRACTOR'S HIPAM OR SUBZONTRACTINO SIGNATURE CfRTIFIEO THE FOLLOWING: 'I CERTIFY TWAT IN THE PERFORMANCE OF THE WOW FOR WH-,74 THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SURUECT TO WORKMAN'S COMPENZ0kN PAWS OFC ANIA.' THE A" UCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL RFOUIRED INSPECTIONS- COMPLETE DRAWING BELOW. SIGNED X TITLE: •i.�� 'Y,i��I DATE: PLOT PLAN(DRAW TO SCALITI SCALE Ill 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY, 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYS ORL POKO t 2. OUTLINE OF THE PROPERTY,WITH TIIM"MIONS AND NORTH DNECTION" EXPANSION OF SEWAGE DLOPOBAL SYSTEMS�.11 c I( 3, DIMENSIONED OUTLINED AND LOCATION OF ALL EXISTING AND IMlOPO REO RTRUCTURC-.B, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE7R �I ON ED INCLUDING COVERAREAS SUCH AS PATIOS,ONVEVVAYS,AND WUWLS. THE PROPERTY OR ADJOINING PROPERTY. 121' ° .. .. .:... .. ....... ... Y :....�`: L.(� ,.. _ : ... . .. ... c ,Q . i. .L. ........;". ... .. ........ ...., .,.... .. I t Ali ., e• t t j• , ... .... ! .. : vit i 777�' - o. . r" ,,. ..... .". .. .t ... ..y... .... ..e.... :. ... 3 : , : FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED DY �+ / /i✓l /)_/�1__fl 11 Cy -�`U DATT: J AREA' r G Y R ]RUMP INSrECTION SY GATE ./F [- FINAL INSPECTION SY' _ OATC- L T ADDITIONAL COMMENTS; �TTT ACCOUNTING ONLY: ND/ FAC# PE CODE FEE INFO AMOUNT RLMI ITED CIIEc Jc ASH RECEIVED BY DATE SR r POVAT NUMBER INVOICE/ S 60/1-2- 6Z PL'D,Health Serv,-Erlviro.174(3;96)