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p� APPLICATION FOR 110UID E PERMIT <br /> SAN TOAQUIN COtT?4°R'•pLil�[{`I1�Q �I FU� <br /> HEALTHEALTH SERVICES <br /> AL H DIVISION <br /> 4104.iA57 ER AVENUE,570CKTON,CA 95202 <br /> SPECIAL I'EkNii 1T (209)468-3420 <br /> zo3 2 3 RON•REFUNDABLE PERMIT EXPIA 8 1 YEAVEAl I.FROM DATE ISSUP <br /> lcoapiFt.rR 71ipr— <br /> APKWA'FXM M HEREBY M D THE SAN JOAONN COUNTY FOR A PCRMTT TO CONSTRUCT AND"INSTALL THE WORK DESCRIBED.THIS APPLICATION I.MADE IN COIAPUAHCE MITN BAN <br /> JOAQUIN COUMY IDEMCKIIIIII&TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF Q.y!JOAOVM CO PVBLIC HEALTH <br /> _ _ > /• - ' HEAL�TGH SERVEO.EWAMP ENTAL HEALTH DrVMO�Nr. <br /> JOB ADDFESSIOR APNJCl /:� LOT-SIZEzy� <br /> A <br /> OMMEWO NAME -4 PHONE <br /> CONTRACTOR� MJrZAC+ LrCAA-'C ) G � <br /> J <br /> LICT Z2S PHO�JE �3•S� -J <br /> ELM CONERACTOR ADDRESS LICA RHONE <br /> TYPE OF SEPTIC WORK: NEW INFtAELAn*N PEF,mmAmnom❑ DESTRUCTION❑ <br /> DO)SEPTIC BYSTEM PEFMrMD IF F-MUC SEWER IB A-11.ABLE WRMN 200 FEET OF GUIDING,) P61C TEATIN)I I Now MAAIT <br /> \��Z," NPSE.IInR Fv <br /> wSTALLATION WILL.EINE. RESIDFNC�-LJ COMMEIICIAL❑� OTHER❑ <br /> NWRM OF LFIANO UMTS: NUMDER��IO�F ED1100N4: NUF�IN OF ISM LYlllt ((�� <br /> ER OF SOI[TO A DEPTH OF]FEET�fL4�k cI PITJSUMP SOIL CHA.RACTEP:C� //�� WATFR TABIF OEPTN��*� <br /> OE►FTC T IAOREA/E NIAP ❑TYFEi1NF_ A'EL• - 4__o CAPACITY AT!©Li NO.COMPART TENTS yy�� <br /> IATREATMENT PLANT Q DISTANCE TO NEAF-VIT: WELL`57G INE l' FOUNDATION lGi PROPERTY E ­o <br /> UFT STATION 0 SIZE TYPE CF PUMP SAND Ol SEPARATOR(ENCLOSED SYSTEM) <br /> IFACFENO UNE o- NO.B LENGTH OF L1NEB ?-�2�1 AT"7\"/�, DISTANCE TO NEAMST:WEiI U N; FOUNDATION 7� ` FROPERFY LINE !DLA '✓ is <br /> FILTER SED CT WIDTH tENOTH_ DEPTH DISTANCE TO NEMEST:WELLMUFAJATION F"OPERTY LME <br /> MOUNDED L❑WIDTH LEMTH _DEPTH OWAWE TO NEAREST:WELL FOOMATION PROPERTY LINE <br /> .EFPAOE NTS /CJ DEPTH L I IM __^FIUMBER.- DISTANCE TO NEARE.T:WELL FOUNDATION PROFERTY LINE <br /> F <br /> LIMPS ❑NfDTH LENGTHDEPTH "STANCE TO NEAREST;WELL -FOUNDATION PROPETOY UNE <br /> ".POSAL PONDS O WIDTH LFIN <br /> ITH `DEPTH DISTANCE TO NEATEST:WELL FOUNDATION RIDPCRTY LINE <br /> 1 HERERY CERTIFY THAT I NAVE PREPARED TMS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH PAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RVE19 <br /> AND AFOULATIONe OFTHF SAN JO EERY,NOME DRAINER ORLICEkDAGAM'S SIGNATUREClRTS'IE.THE To11oKvIN0:9C@fTIFYTHAi NTNE PEISOI..IANCEOFTHE WO1K FORWHCH <br /> TNIR fE ED.1.HiA.11 EIMi ANYItTiIK)N M S1fCHAMOBECOMENIBJECTTDN'OPKMAN.'SCOLIPEIMATDNlAWYOFCALIFOINI"l'COMRACTOR'SW/VNGOR&J6Co TINGHLLOMTNO •ICCRTIFYNAANCEOFiNE WOfK FOAWHICHTHIS FERIAR IR IBSl1[D.1 YIML ELOLOYP£RGOHS SUBJECTTO <br /> W WMAN'B CO ION OF A.• INE T2A/ROLRIS IN ADVANCE FOR AL1.11EOLr{ID INSRECTIONS. COUPLETS ORAWINO BELOW- <br /> SMNED,k Trtll' _ DATE: <br /> I ` 1 PLOT PLAN IDRAW TO tX:ALEV RCALE_ 4_'t� <br /> 1.NAMES\OE-,Y_)yREETS ORAD FAEB:ST TO OR&MI NDNG TIIE ERTY <br /> PROF . t.LOCATION OF HCWW SEWAGE DISPOSAL SYSTEM OR PROPOSID <br /> 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS ANANWN <br /> D NORTH DIRECTION- EXPOOF SEWAGE OIMDSAL SYSTEMA <br /> 3."MEN SIOFED OUTLINES AHO LOCATION OF ALL EXISTING AND PROPOSED STRUCTURE&. 6-LOCATION OF WELLS WTTMN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. THE PROPRITY OR AD.101 PROPERTY. <br /> a <br /> - <br /> 1 . <br /> .. . .... ,LSM <br /> - <br /> - •E2•g999g;.... <br /> 4. : sAN•JOA <br /> UliIN Cuunrl- <br /> •..ENVIF9G EN AL H SERVECEy <br /> ... ...... .LT <br /> ... . .• .. .. ..... _..:.. . .... . .... ... H DN{gra <br /> FOR OEPARTAILI'IF USE ONLY <br /> APPLICATION ACCEPTED BY ( DATE: /]��� AQNEA: / SQL <br /> TANK,PIT OR SUMP INSPECTION BY {' N DATE ) FINAL INSPECTION BY lk'< `U"V.F<-R."I TTATE Y7 J J T/ AJ <br /> ADDITIONAL COMWENT9: <br /> NeL_J F-- -6Y\ -o2y rte`, - <br /> ADCOUNTOIO ONLY: <br /> IME CODE FEE INFO AMOLNT P9AITED IIf.CN AE/i RMCVM ST DATE SRW I PVR.T NUMBER TNVOiCE E / 6 <br /> Pub.HoaM Son,•EnWo.174(3186) <br />