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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> �1 I 304 E WLSEkAVE-3"°FL-5TOCRTOn CA 952PZ - (209)468-3420 <br /> I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> k. FCROS$STREFT <br /> ONRFUNDABLE PERMIT CALL(209)953-7697 FOR INSPEC'TION'S EXPIRES 1 YEAR FROM DATE ISSUED <br /> I1� SS i I �- CITYIZIP <br /> APN -�T- PARCEL SIZE <br /> ik PHONE ��ME l DRESS _ CFT'V7STA7EIZ[P- - `i'- ` i <br /> f <br /> -a PHONE <br /> CONTRACTOR `.I-- j'4 <br /> - CITYISTA7EIZIP e-'J i.-i' r� i-I i, <br /> CONTRACTOR ADDRESS <br /> + <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> 1 PERC TEST # t BUILDING PERMIT# LAND USE APPLICATION <br /> 111^^^ <br /> IVE <br /> TYPE OF WORK: ❑ NEW INSTALLATION <br /> fl REPAFRlADDITION ❑ ENCINE£k DESIGNED!ALTERNAT <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> I�I INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL C3 OTxEA <br /> 41 1 NUMBEROF LIVING UNITS: NUMBER OF BEPAOOMS: NUMBER OF EMPLOYEES: <br /> L1r+�. ❑ SEPTICTANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> L '� ' ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> t ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL It FOUNDATION ft PROPERTY LME ft , <br /> Q LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS <br /> #OF LINES LENGTH OF LIMPS ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> i ❑ FILTER BED WIDTH ft LENGTH tt DEPTH ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION fl PROPERTY LINE ft <br /> _ ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ sumps WIDTH ft LENGTH ft DEPTH - R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION- ft PROPERTY LME ft <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPru R <br /> I ft PROPERTY LINE R <br /> DISTANCETONEAREST WELL ft FOUNDATION <br /> f ❑ SEEPAGE PITS NUMBER -WIDTH ft DEPTH R <br /> 'DISTANCE TO NEARF-4T_ WELL w ft FOUNDATION- - -^Y 11 PROPERTY LINE R <br /> pe{ 1tt h� <br /> - a I HEREBY CERTIFY.THAT 1 HAVE PREPARED THIS APPLICATION A WORK WILL BE DONEIN ACC <br /> ANTHE FORDANCE WITH SAN JDAQOIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQU1N COUNTY <br /> r <br /> 1I 2CENOTICEREQUIREDFOR <br /> .INSPECI'lD11Nkk5fPLEA <br /> MNUM 4 OURADVAN <br /> S CALL(204}9537697 /// <br /> TITLEt,Y\4r( .a 1 DATE <br /> SIGN <br /> • <br /> Z i�M <br /> ^12 <br /> `. <br /> v.75 neGNEr E <br /> 14 26 <br /> FI .� 75 <br /> I A - P. M. 6k.09 Pg.T O 1 <br /> -. _ P. M. Bk.10 P 166 ° NTY, <br /> 9 9 } , <br /> L -F. S. C2572 <br /> I D -R. S. C4203 <br /> R M M- Bk.17 Po.145 J y 4 H L H E 4T <br /> e —R. s. clsea <br /> - NOTE: Assessors Pnresl Numbers .51 <br /> �� �` Assessor's Block Numbers Sh <br /> .. r DEPARTMEN'T,USEQ NLY <br /> p <br /> Area Employee Ip# <br /> Application Accepted By i�_::��r � ' L�_�- Date I � a I !'•' <br /> �j Date ❑ SPECIAL PERMIT-Approved by <br /> Final Inspection By <br /> I Character of Soil to Depth of 3 Ft: PitfSump Soil Character: <br /> j COMMENTS <br /> Flk <br /> I Permit! <br /> pE, SC Received ( Checldl�� Amount DaleInvoice# Permit[D# <br /> Code INFO B "Ce"s)I Remitted _ Service Re uest# <br /> lel c ` ONSITE WASTEWATER PERMIT <br /> 42-02-001 <br /> t Jf7]17fN13 - <br />