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n 'r�ll APPtiC t10N FOR uaUIQ IT << SAN JOA)DUIN COUNTY PUBLIC HEAD ,"Tr`� �ifYIRQNMEATAI HEALTH OIYISI �;?� ' 5' �AZy IpAQv` F►;+ BOX El1ST WEBd.AVMV-,STC �� I?Atl, (209)488-3420 trDll'1 � �E U NOR-REFUNDABLE PERMIT EXPIRE!1 YEAR FRIDEOA lSUE J {GRIYIATA M ST*RntAl APPlCAT10N IS bXPEBY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CON11TRJCT ANUJOR INSTALL THE WORK DESCRIBED.THIS APPLICATION Ii MADE IN COMPLIANCE WITH SAN �IqAOUIN COUNTY DEVELOPMENT TITLE.CCHAP11012-1110.3 AND THE BTTA�N,D,A�R}DB OF BIW JO AOUIN PUJKJC HEALTH SERVICES,ENNRONMENTAL HEALTH DIVRBI)N. I JOB ADORESSIOR AP.0 I:Z';7�' �.`• L ,y0�'7 �p --LOT UMAAV 11.,�0,'Iy ,�,{ • LRY !' 1 OY.NER'S NAME/�IN �I.C� 'ADDRE88 I CONTRACTOR 41.3 s s CONTRACTOR ADDRESS TYP[OF 601"C WORK: KEW LNSTALLATION❑ IIFPAIRIAVONTON Dp TRUOTION❑ KO SEPTIC SYSTEM PERMITTED F PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF 8UILDINO.1 FERC TpTfii I 1 NOW MANY � APSlwear.f INSTALLATION WILL sum: RESIDENCE L 2(�COMMERew rr OTHER(J NUMBER OF LINO UMTS: NUMBER W BEOPOOMS: NUIVAM OF EMROYM:/L-/IS 0 h OF ❑3 FEE7:1 �R PRifft) SON CHARACTER; eWATER TAKE OEIH PCIRT A7TRA►DH 7�PL CAPACITY )1a00�A4. NO.C(W0A�RTMFNTG FIT [J•�` RANT❑ DISTANCE TO NEAAEIET•. WELL _ -f' FOUNDATION /G RID!'ERTY UNE LFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR IENCLODED SYNTEW LEACHING UNE ❑ NO.B LENGTH OF UNES_ DI9TACE TO NEmWVT:WELL F40UNUATXW PROPERTY LME FILTER NED ❑WIDTH LENGTH DEPTH DISTANCE TO NEMEBT:WELL___FOUNDATION PROPERTY UNE MOUNDED �❑I,WIDTH LEMTH DEPTH DISTANCE TO NEAREST:WELL FOlINOATXW PROPERTY UNE SEKPAGE PITS CYowTH _SgE�R NUMBER 3 gSTANCE TO NEAIF97:WELL FOUNDATIIN/,10 FRoPERN SUMP ❑WIDTH LENGTH OEDTH DISTANCE TO NEAREST:WELL FOUNDATION PROFERTY UNE J DISPOSAL POND{ ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROFERTY LINER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT TK WORK WILL BE DONE W ACCORDANCE WREN SAN)DAWN COUNTY OROWANCEB AND STATE LAWS,AND RULES ANO 8OFTHESANJOAOUINCOWrY.HOMEOWNERORUCENML AGENTS SIGNATURE CERTFIESTHE ILLOMANG:'I CERTIFY THAT.THE PERIM OAJCE OF THE WORK FORWHICH THIS p: tab ED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A NNERAS TO BECOME SUBJECT TO WIXKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S NRMIO OR eU8{ RACTfN A CERTF THE fOLLOWF/0:7 CERTIFY Ai IN 11.PERfO .l OF T.IPR?PK FOR MRKCH 7141*PEMAR M WSUED,1 SHALL[MPLDY PERSONS SUABLE"YO AN'6 COM N THE APPLLCAN T CAU,Sia HOW IN ADVANCE VIM ALL R[OLMSO IMSf�YIONS. COWALETE DRAWING SELOW. ['w// t -S 7 Bl K 7RLE: DATE: — J PLOT PLAN RAW-- ALE)SCALE -I. l n 1.NAMES OF S'fREETB DR ROAD$NEAREST 70 OR BOUNDING THE PROPERTY. 4.LOCATION OfHIOUSE SEWAOE DRARVMAL SYSTM OR PRDPOBED �\ 2.OUTLINE OF THE PROPERTY.WITH OWENSIOHS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 0. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S.LOCATION OF WELLS WITH.RADII DR I Of OW HUNDRED FIFTY FT.ON K� 61CL,JDSM0 COVERED MEAS SUCH AS PAM$,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJON040 POM", , }� Ik T Af 4 1a91, �u�.A� rc yc r iNfM` SBd cd�°T �• [ :ei t.FI ;rgtST+C R ... ec •''v' +Ed-r�z p p,,n•aV' ev. . . . .. ... .. :..... . FOR DEPARTMENT W[ONLY ATPLICA7ION ASCT,FD BY DATE: f AREA,—�� TAPK ,bR VyS PAY INSPECTION SY L' DATE n `7ANAL INSPECTIDFIBY — DATE�, 1 w ADD17roN l :fM EMB. `r' Ix ACC)RATING ONI,V� A1D1 FAC/ 1i►� PE CODE FEE INFO AMOUNT PAmT7PD CNEC AIH R1.CBVm BY DAT[ ER J FMIBT PRIMBEI INVOICE S 0 a+�t�o3llR -