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Ceu.Innniiiufn�iurvFNONSITE viRnKwrNTAi FWAI TASTEWATER TREATMENT SYSTEM NPERMIo ;IP'M eA -r- 7 <br />NON-REFUNDP IdFT CALL 209 953-7697 FOR INSPECno S EXPIRES 1 YEAR FROM DATE ISSUE[ <br />JOB ADDRESS QCITY/ZIP Q� '? <br />CROSS STREET APN 05 it 10 _U ��%PARCEL SIZE *33 33 <br />OWNER NAME ASS O� Y PHO4E <br />'�yV CITY/STATE/ZIP Look <br />OWNER ADDRESS <br />^ /V–�A�� jk111 �% <br />CONTRACTOR , A • — 1 WsM - 5� � ! PHONE � ✓ U� V� <br />CONTRACTOR ADDRESS _ ® w�–�JKJ /�+ ` CITY/STATE21P cA <br />LICENSE Y" C-42 ❑ C-36 OTHEIIA NUMBER1 019'5 U EXPIRATION DATE 4r I <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X _ Y <br />D <br />PERC TEST # <br />Date <br />Permit/ <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />❑ NEW INSTALLATION <br />REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />Service Re uest # <br />I-] REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION <br />INSTALLATION WILL <br />SERVE: RESIDENCE <br />0 COMMERCIAL ❑ OTHER <br />�ry <br />`C! <br />NUMBER OF LIVING <br />UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ <br />SEPTIC TANK <br />a <br />TYPE/MFG <br />CAPACITY ® gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />� <br />�} (� <br />10 • 35' ft <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION cJ It PROPERTY LINE <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEq}3Ea WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />P FIJI <br />_ <br />�;7ft <br />$I <br />FILTER BED <br />WIDTH ft LENGTH <br />DEPTH ft <br />DISTANCE TO NEAREST WELL 564' <br />It FOUNDATION ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE To NEAREST WELL <br />It FOUNDATION ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION It PROPERTY LINE ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS`COMPENSATION LAWS. <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Depth of 3 <br />COMMENSS � <br />Area Empioyee ID# <br />❑ SPECIAL PERMIT - Approved by <br />PE <br />SC <br />Received <br />Amount <br />Date <br />Permit/ <br />Invoice # i� <br />Code <br />INFO <br />B Cash <br />Remitted <br />Service Re uest # <br />3 <br />cU <br />2- <br />�ry <br />`C! <br />6R -00-7 060-N <br />a <br />42-01 ONSITE WASTEWAT� 1�1. #81 ��PAI <br />ERMIT <br />5/5/17 �ACTy 0NNNNNNMEN7At <br />T <br />