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JOADUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION I ,77' 1"'&d nA A43 P,O. BOX 388, 304 EAST WEBER AVENUE, ST l 7 {'1; OA'gb20.1, (209( 468.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE"�et�r+.�1� (Complete in Triplicate) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAdUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ! JOB ADDRESS/OR APN/ c[� ` .� CITY \� t-K�Y LOT SIZE 1L', OWNER'S NAME ' 3 ADDRESS 51-Eng- �+✓ �1� UCI +:/�PHOPHONNE CONTRACTOR 'L ,r ADDRESS`1L. (J ` l_�'�"r"7� SUBCONTRACTOR ' ?T ADDRESS UCI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION•\ REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIO I 1 HOW MANY Appllontlon I INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIALS OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: C i 4k CIL,() CHARACTER OF SOIL TO A DEPTH OF 3 FEET:_ / P_I,TIS,UMP SOIL CHARACTER: ,�`yam WATER TABLE DEPT/1 SEPTIC TANK/GREASE TRAP DSI TYPE/MFG S ,` W Cy1�, CAPACITY `CX l J - F-1n NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SW:' E F MP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING LINE xO.b ( DISTANCE TO NEAREST:WELL_FOUNDATION1�PROPERTY LINE r FILTER BED ❑WIDTH LENGTH H DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFI, THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM NS TION W8 OFKALIFOR THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE: LItIA' DATE: I OT PLAN(DRAW TO SCALE)SCALE 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. :..._................................. .........._... .. ..... .. :.. . \� � :..... . �N Qt . �9 d ......... .............. ..... : ...;.... . . ... .. . a Lo ....:......:.. . ... .... .1. ........... ... ........... ;.....: ....... .:.. . ... .. ..... ..........:................................... . .......>� .. 1.....o� .......... . .... .... ....... .. . :....................:........... . .. . :... ..:. . . : .. ..... ? ................. ....... . .......... . .:.....:... ..:......:.....: .. 70r io*b' ........................ ...:................. . . ...:..... ..:......:......:.............: ...:....:........ . :.. ..:.... .. . . ...... .: . ..: FIA r a. ... .............>.............:........................... ... .......... .......... ........... ... FEB 2g g ................. .. ....... __ _;k FORM DEVi _ r'US4mwLY4F4j 7fi C7rVl`.• ! (f , APPLICATION ACCEPTED BY 1�/�`L/'`�" Q ��-/�1�1i�R. > DATE: / AREA: ` TANK,PIT OR SUMP INSPECTION BY DATE / / FINAL M INSPECTION BY DATE_?, / /7 yJi ^ —5 C1/ 1fCST / I C� IlJ �.ltiQ x,63 1f�felJ ADDITIONAL COMMENT 1' '/� .� Bauer - ,uo SCRE�,s our TrCiKT 1.14.*, r W� S E SYN At GF�JUI,v�N:,T„N r)fwK ACCOUNTING ONLY: AID# FAC# oK glopKu,J�, tluPj,4 u r4K<.4NtiIVAT"u PE CODE FEE INFO AMOUNT REMITTED HEC /CASH RECEIVED B\' DATE SR!PERMIT NUMBER INVOICE I J C-4— I Pub.Health Serv.-Enviro.174(3/96)