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S.ANJOAOUINCOUNTYENONSITE VIRONMENTAL EWAALTH DSTEWATER TREATMENEPARTMENT T SYSTE. EM NPERMIT CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS / ,✓� CITY/ZIP `J�B'P��G�Z✓,il� �� /��/� y CROSS STREET 1-�y i��r �/1� APN 1 v ✓V 1 PARCEL SIZE p d OWNER NAME PHONE f OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR /,� ��/r�I S �/ // G l/I.tA f &oa PHONE CONTRACTOR ADDRESS / �� /1/i✓�� .L CITY/STATE/ZIPA � ,� LICENSE I I C-42 I I C-36 OTHER NUMBER EXPIRATIONDATE�/1� —'��/5�5 9.1 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: �. NUMBER OF EMPLOYEES: 4f D ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPAR N4 ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF C6%ft ENV C.DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPE*(ZgL Q_ 1ANVOW Ou�[TyNTM ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(EN LC7Le& 'v�yyE- M) LEACH LINESLEACHING CHAMBERS oc,,OV #OF LINES LENGTH OF LINES l , ft v — DISTANCE TO NEAREST WELL 5 ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAFOST WELL ftF N)DATION ft PROPERTY LINE ft 0 SUMPS WIDTH 1/ ft LENGTH ft DEPTH /�� _ ft DISTANCE TO NEAREST WELL /00 1l ft FOUNDATION O ' ft PROPERTY LINE 5 �- ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ElSEEPAGE PITS NUMBER WIDTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINNaM�WHOU VAN E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED TITLE CXZ3 DATE 211 EPARTMENT US'E ONL Application AcceptedB Date Area C Employee ID# Final Inspection By S.cd Date / ❑ SPE IAL PERMIT-Approved by Character of Soil to epth of 3 F Pit/Sump Soil Character: COMMENTS PE SC Received C / Amount Date Permit/ Invoice# Permit ID# Code INFO 131n Cash Remitted p Service Request# UV t 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17