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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388.304 EAST WF -BF -:R AVENUE. 870WMN, CA 95201388 <br />{2091 481.3420 <br />000-BEFURBABLILPJNWJ EXPINES I TEAT F100) DATE ISSUED <br />(Ce"Ists IS TT#0TNS) <br />APIRUCATFON IS MISS NAGE TO TM SAX JOAOUN COUNTY FOR A PERMIT TO CONSTRUCT MERG" NSFA1L THE WOW VEOCNKD, TWO APPLICATION IS MAGE N CCOORU CE WITH SAN <br />JOAGLRN COUP.TY DiVROPMof► TTTM CHAPTER 0-%110.3 AND THE IRNDARROS OF BAN JOAOM COUNTY WbIIC HMTH t6NICEb, lNVEIOIIAOFTAL HFALTH DIVISION. L <br />JOE ADOMOSM ,~ rr C MZA G ^.'PLY M1U CRY ki C o LOT eve___ qQ ./�1 <br />oHI1PIWs NA1AE�y{ [}�' �Y� )C/. -L i[4 AWfEE6 S �'MQ// <br />COMRACTDR��O_ L [ C ` ADDRESS � d _ $oy. [yS1h _LJv � PNONE,a-'�S 7 i 'S <br />SUE COMAACTOR AppESS LRCI PNOW <br />TIKE Of SVTIC MOMS NEN INSTALLATION ❑ MPAN/ADDITIDIf i7 DtrNNGTIOR ❑ <br />'SG SEPTIC rnrn%A PERMITTED IF PRNLLC BEVJM IS AVAILABLE WFTHN "0 FEET OF SUKOMP03 PNLQ TSTFI l 1 NOM MART <br />AwMAMRI <br />WISTALLATION WOLL OWML. FESDW1 $COEM/EFCIK ❑ OTMA ❑ <br />PRSNNI OF LIVNG UETS:_L HUF\SU of SMFOOMS� 3 NJMM OF SAPWYOt: <br />CNIUAIi;M OF sok TO A DEPTH OFf3EET3FFS GN4 Y PFTIVLW bon CHARACTER_ MATER TAKE D"T?L_ <br />VTt <br />STANKNNAM TMJ i7T1'K k" r +-(_ CAPACITY - .. 1 7�_fK) NO. COIPARTTAOM <br />PRD TTEATOYrT FLAFT ❑ ONTAN IN TO NRALSST: WILL (d6 FOUNDATION I d PPIOPERrY LDe, <br />LFT STATION ❑�StZE— TYPE OF IV NP SNp OIL SEPARATOR IENCLORD SYSFOI I <br />LSAgOq LINE NOId •MEIN. of U. 3 a INSTANCE TO WARIEST! WELL -: n , FOIMDATIOP,_jtjp_ PROPERTY LOW <br />PFLTNL BSD ❑ WTOTH LENGTH_ DEPTH DISTANCE TO NEAREST: W01_ FOUNOATtON I PR unwrY LIFE <br />RIOtNM ❑ WIDTH LENGTH OEPFM DISTANCE TO REARESTI V6711. FOUNW TION PfDPEIFFY LSS <br />SONYE RTS ❑ DWTH SIZE _ NUMMI DISTANCE TO NEAREST VVUL POIINOATION PROPOIFY LpC <br />SUAPM ❑ WSTTH LENOTH-- _DEPTH INSTANCE TO NEAREST: WFLL F"JNDATIO/f PROPLfFTY LSIE <br />DNPOEAM Palms E) YORFM LENGTH__ OEPTH INSTACE TO NEAREST: W9L FOINDATTON RROPEIITY I>rN <br />11106SY CERTTY THAT 1 HAVE RIEPARM THIS APPLICATION AND THAT THE WORK WSL SE DONE M ACCORDANCE WITH SAN GOAOUIN COUNTY ORDNANCE! AND STATE L"M AD HIILIS <br />AND REGULATIONS OF THE SAN JOAOUN COUNTY. /ROME OWRER OALC NWO AO WT'S NONATU E CPFTWKG THE FOLLOWPOW '1 CERrWy THAT N TIA FpFOI MANCS OF THE WORM PON WHICH <br />TSS ROOST N ISSUED, I SHAIL NOT EMPLOY ANY PERSON N SUCH A U.W MR As TO BECOME SULIECT TO WORKMAN's COMPENSATION LANES OF CAII►OINA.' COH 110A " 1NNIS OR <br />BUB-CONTRACTRPO SIGNATURE CEKrIP" THE FOLLOWING: n CERTIFY THAT N THE PERFORMANCE OF THE WOM FOR WINCH THIS PENAFT TO ISSUED. 1 MAL EMPLOY PUMPS SU6RCT TO <br />WORKMAN'S COMPENSATION <br />/(LAWS OF CA IPO/WIA.' 41� <br />THE APPMANT MUST CALL 24 HOURS IN ADVANCE FOA ALL PWJMW IR SPOILMRSS. CO"Un OIAVNp BROW. <br />k V l N"�/ T.; of ) /1�Fi 4T'ta! DATE <br />PLOT FUN SNUW TO SCALL) SCALE - M <br />/. NAMES OF STTHTS OR RDADB NEAREST TO OR NOUpp THE PROPPIITY. <br />S. OUTIJI E OF THE RMDFE/DY. WITH DIMENSIONS AD NORTH DMFLTION. <br />3. GNAENSIONED OUTLlEt AND LOCATION OF AL FJOSTBp ANO PROPOSED STRXMPK% <br />NCILONS COVERED AREAS SUCH AS PATIOS. DRIVEWAYS, AND WALK$. <br />4. LOCATION OF HOUSE SEWAGE IN NPOML iYSTW DII FIAFOs® <br />EXPANSION Of SEW AGE DISPOSAL STSFOA. <br />S. LOCATION Of WELLS VTIT IN RADIUS OF ONE HU DP® FIFTY FT. <br />THE PROPERTY OR ADJONOM PROPERTY. <br />FOR DEPARTRIOIT USE ONLY <br />APPLICATION ACCEPTED SY —-- pATE:� VEA• <br />TAN(- RT OR SUAP NBFECTPJII BY DATE 1 / FINAL WSPECTNON by UA71 ! f <br />ADDITIONAL COMMOITK <br />ACCOLNTTIFO STAY: NOF FACE <br />I's OOmE FFE NM ANgLSIT PIUIS IYm CHSCIV IISCEVFO by DATE tR Ira". RUNNER UFVGICE S <br />�. (C1 l I --, I 1 1r r-) 1 -T uf, R I Q 1 A I / a,, /OK 6 02 <br />Aum. HsalM SLNv. - EnrlrG. 174 (3/861 <br />R� <br />