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SAN.1DA4UIN COUNTY FUSIDIC MERLIN SERVICES <br /> D®ll <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 988,904 EAST WEBER AVENUE,STOCKTON.CA 96201.888 <br /> (209)485.7420 <br /> NDX-REFUNDARLE PERMIT EMUS 1 YEAR FROM DATE ISSUED <br /> (complete ill Trip6Le14 _ — <br /> APPUCATgY le HEREBY MADE TO THE SAN JOAGUIN COUNTY FOR A pERMTT TO CONSTRLICT ANb/OR INSTALL IHE WOW DESCHSEb.THIS APPLICATION to MADE PI COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAFE FA 8-1 110.3 AND THE STANDARDS OF SAN JOAOLRN COUNTY PUBLIC HEALTH BEIIVICEB,ENVIRONMEMAL HEALTH DIVISION. <br /> JOB ADg1E68/OH APNf /'( `Z' f TF 1(j,yk 7_ < �/// <br /> •�`>�hcIKTDi'L CITY -�-� •—�r�-' LOT SSE <br /> OWNER'S NAME d f0 ADDREse 1�L JS <br /> COMTUCTOR > /H�O -roc `7 (� <br /> �� AODRES6� LKI PHONE_ <br /> SUB CONTRACTOR ADORESs UCf PRKTrTe <br /> TYPE OF eEFTIC WORK; NEW INSTALLATION REPAIWADDITION❑ DESTRUCTION❑ ` <br /> IND SEPTI;6YfirEM PEMAITTED M PUBLIC SEWER b AVAMSLE WITHIN 200 FEET OF SUILDINC.) "AC TE6TN1 I T HOW MANY <br /> Applleden I <br /> ER _ <br /> INSTALLATION WILL SVE REBIOMCE 0 COMMERCIAL❑ OTHER❑ <br /> Mwtain OF UNNO UNITS:_NUMBER of BEDROOMS:_ . NLMeER Of 6NPLOYHS: _ <br /> CHARACTER OF SOI.TO A DEPTH OF 3 FEE': PIT/SUMP SOIL CHARACTER: •�� WATER TABLE DEPTH <br /> eEFTIC TANKMIREASE TRAP CiTYpE/MFO Sctle 'Ti}uK CAPACITY f?✓V NO.COMPARfMEMS,+ <br /> PILO TREATMENT FIANT❑INSTANCE TO NEA\FET: WELL__. FOUNDATION pROPEIII UNE �J / <br /> LIFT STATION❑LEACHING /SEIZE TYK OF PUMPSAND OR SF.PARATOR[ENCLOSED 9YSTEMI y <br /> LEACHING LINE d NO.6 LENOTH OF LINES_42 -'DNJ DISTANCE TO NEAREST:WELL��FOUNDATION PROKRrV LINE AIPP�j f <br /> FILTER BED ❑WIDTH LENGTH- DEPTH DISTANCE TO NEAREST:WELL FOUNDATM PROpERrY LINE <br /> MOUNDED ❑W10TH .•� IENOTH _DEPTH DISTANCE TO NEAREST;WELL FOUNDATION FROPERTY LIFE <br /> SELRAOE NTS C pEE7H rJtS! SKE�__NUMBER— Z DISTANCE TO DEAREST:WELL�T FOUNDATION PROPE/ITV LPIE <br /> LIMES ❑WIDTH LENGTH DEPTHDISTANCE TO NEAREST:WELL FOUNOATION PROPERTY UNE <br /> DISPOSAL PONbS ❑WIDTH LENGTH OfF'TH DISTAJJCETO NEAREST;WELL rOUNOATON FROPERTYUNE <br /> I HEREBY CERTIFY THAT 1 HAVE PLIFPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN.21AWIN COUNTY OFIDINANCES Aho STATE LAWS,AND RULES <br /> AND REGULATION: THE SAN JOAGUIN COUNTY-HOME O WNER OR LICENSED AOENT'S SIONATURE CERTIFIES THE FOLLOWING:'I CEIRIFYTHAT IN THE TERNOPMANCE OFTHE WORK FOR WMCH <br /> THIS PERMIT IS 16 UM,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AD TO BECOME SU-JECT TO WOWMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HSNNG OR <br /> SUB-CONTRACTI I NATURE CERTIFIES THE FOLI.DWRM:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WM;CH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT 70 <br /> WOPNMAN'S C PF SATION <br /> T= <br /> OF CALIFORNIA.'THE F/P!SANT NUET CAU,34 NOIARf IN ADVANCE FOR ALL REQUIRED INSPDGTIONe.COMPUTE DRAWING BELOW. <br /> SIGNED � TOLE `� DATE. <br /> ROT I.Z IDRAW TO SCALED SCALE _'Uo <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PFA"SED STRUCTURE-11, G.LOCATION OF WELLS"THIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING RE <br /> COVED MEAS OUCH AB PATIO%DRIVEWAYS,AND WALKS. THE PROPERTY DR ADJOINING RIOPEFTTY. <br /> ...i .................. - .. _ ...... .... <br /> ... ... ..... <br /> : .,.. . . <br /> ...:.. P r .. � <br /> _. ..... .. ......:... .......... <br /> I <br /> .. '. �.. <br /> ;. . . <br /> ..:............. <br /> Li <br /> w. Of 0° <br /> 3j± .:.. . .~�.. .. .:. .. <br /> 1 <br /> /� ,�L FOR DEPAA7MENT UBE ONLY <br /> APPLICATION ACCEPTED BY__ I�JlfiYf� cQ DATE: 4/—/0-177 AREA: <br /> TANK,RT OR GUMP INSPECTION!BOfDP.TF. / / FINAL WS(ECTION BY -IS'E 7'/ <br /> ADDITIONAL COMMENTS: <br /> Y <br /> ACCOUNTING OP.LY: ADf FAC/ <br /> PE CODE f 1 AMOUNT REMIT TED IEC ASH RECUVED BY DATE T NlA4S01 I/FVOrCE F <br /> - �o lata <br /> Pl;b.HeaRh So",-ErMro.174(3,196) \ <br />