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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREE �'I I <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS E <br /> JOB ADDRESS E• �.LTa N ' CIN/ZIP M�fV- <br /> CROSS STREET fM In N I-Ec� A Ai <br /> 1/� APN --S 1 2-2-4:) - 'S, rn� •' 1l ✓ <br /> OWNER NAME M A T•�G��T L w Aiy PH, <br /> OWNER ADDRESS I (P-7 r-1 �- PW 5-Ti(IJ CIN/STATE/ZIP MAI 1 <br /> CONTRACTOR w\fc Dp<w- GCaE�1VI��1'�fNj�( PHONE 3y1" 4i21 <br /> CONTRACTOR ADDRESS 40-1 w 0 Pole S t CITY/STATEIZIP L-C)' <br /> LICENSE LiC-42 LIC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> X PERC TEST # l BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES L LEACHING CHAMBERS #OF LINES LENGTH OF LINES It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMU HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE 4- 2-14 -19 <br /> A'9y <br /> c <br /> 'P�gq<'r',y <br /> �4> <br /> DEPARTMENTjUjE <br /> Application Accepted By Date AtAl Area Employee ID# <br /> Final Inspection By Date SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS �r�t t4rfi 1�a +l <br /> PE SC Receivedec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Re uest# <br /> t57D l;� 00 sqk--D <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />