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ONSITE WASTEWATER TREATMENT SYSTEM AIN EPERMIT cA95zoz-(209)468.3420 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E EXPIRES 1 YEAR FROM DATE ISSUED <br /> NON-REFUNDABLE PERMIT CALL 209 2's3-7697 FOR INSPECTIONS <br /> Sit y <br /> JOB ADDRESS ( � �� CI t.L. /�-- I�� CITYIZIP 7 t-- L- "-' 1 <br /> i t /f CrTk A APN I j � ' U C) PARCEL SIZE <br /> CROSS STREET _ - <br /> OWNER NAME L L '>T 1 J C " 1 ISI -_�, PHONE <br /> OWNER ADDRESS CITY/STATEIZIP <br /> CONTRACTOR r PHONE C <br /> CONTRACTOR ADDRESS ) -7 L. (�!]'''''N L� r^'y ✓"� CIT/ISTATE2 /�1P �'' ��II �--�-? ` A <br /> LICENSE [�C-42 [IC-36 OTHER t2 NUMBER 0 IL' EXPIRATIONDATE <br /> WATER TABLE DE!'TH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> r❑ PERC TEST # BUILDING PERMIT# � LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION .- REPAIRIAODITION - ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION ~( <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER /L <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: `J <br /> L7 SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASETRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> R <br /> !� LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) h <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES tt <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH_ ft LENGTH ft DEPTH ft y; <br /> DISTANCE TO NEARHST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH _R LENGTH It DEPTH ft <br /> DISTANCE TO NEA RET Ws L It FOUNDATION ft PROPERTY LINE_ It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH it f <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE _ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft I ;I <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE it <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, - <br /> �,._�l STATErLAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> R ; yilNlttJl'tM.>'.4 OUR NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED T 4 tG- / TITLE DATE <br /> 177 <br /> i <br /> SA <br /> HE <br /> I <br /> N <br /> R C U.7 <br /> P F_ <br /> DEPARTMENT UE O Y y <br /> Application Accept r <br /> 1 - �. Z- Dates �.' / Area Employee ID# <br /> Final Inspection Date ❑ SPECIAL PERMIT-Approved by _ <br /> Character of Soil to Vepth of 3 Ft: P17 <br /> Soil Character: <br /> COMMENTS �.!'/_!C u lyJ <br /> i / est 1a l' .9 ' r <br /> FPE SC Received AmountPermlU INFO B Cash Remitted Date Service Re uest# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 10/"7 <br />