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<br /> SAN JOAQUIN COUNTY ENV{RONMENTAL HEALTH TM ENT- - i 304E WEBER AVE;'3 PL $TOCCi A 95202 (209)46&3420 '
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<br /> v IYQIV-RBPUNDABLE PERMIT " CALL` 209 953-7697 FOR�M1'SPECTIOYS n,c EXPIRES 1 YE iR FROM DATE ISSUED
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<br /> 1 r CONTRACfoR ADDREss�' CrrYWATEIZIP
<br /> 1 a LICENSE y ❑C-42 ❑C 36 s�:-OTHER -• NUMxeR - 'EXPIRATION DATE
<br /> .WATER TABLE DEPTH. wx -'ft F 'GEOGItAPH[CAL INFORMATION: CaordlDatas X
<br /> Ll'*'FERC TEST g# k, BUILDING PERMIT#- '` `r -4: - LAND USE APPLICATION#
<br /> TYPE OF WORK O g. NEW INSTALLATION,L'), , ❑3}r I EPAIR/ADDMON r �} ,^ �_L ENGINEER DESIGNED IALTERN_AT{VE
<br /> 'o0:.RR PLACEMENT,1 YC3' rHF'. , d {3'f. : "..❑ 'i DESTRUCTION
<br /> °INSTALLATION WILL SERVE a r,''❑ RESIDENCE e -i`❑ COMMERCIAL a'""'`r #,Q OTHER'
<br /> x '�.NUMBEROFLIVINGUNI75 w,�7*ni w.yr'�n NUMBER OF BEDROOMS �. '23.4.+r ��?,NUMBEROFEMPLOYEES "` .>'r•eL
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<br /> ❑ SEPTIC TANK TYPEIMFG - t''-" i CAPACfIY '? gel #QP COMPARTMENTS
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<br /> ,yrtgt= -0,:,GREASE TRAP 7YPFJMPG 'v^' - ^ i CAPACITY , k gal #OF CGMPARTMENTS
<br /> ❑��,PKC'TXPLANT4 -DiSiANCETONEARESr WELL t S«..fi rFOUN0A710N ft' 'PROPERTYLrNE. ft' r
<br /> �I kr +-❑ LIFT STATION +b SIZE �" ^STYPE OP PUMP ❑u'. SAND OIL SEPARATOR(ENCLOSED SYSTEM)
<br /> ;C]+'LEACH LINES4❑-,LEACHING CHAMBERS '° '" '>"i F-; #,OF LINES;-A rOLENGTH OF LMES ft, .�.
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<br /> -" : - DISTANCE iO NEAREST .WELL ft FOUNDATION R PROPERTY LINE R: .
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<br /> F ❑ FILTER BED --WmTH R LENGTH Y ftDEPrH eft-
<br /> DISTANCE i0 NEAREST WELL FOUNDATION s R PROPERTY LINE Y- ft .�
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<br /> P:ERTY LMt S ' a "rRftDETHWmrH
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<br /> DISTANCE TD NEAREST, F WELL 1 �� �'+-ft FOUNDATIONPROPERTY LINE
<br /> ❑ >DISPOSAL PONDS_.WIDTH -- t "�ft (LENGTH+� s '. r '�R - _'DEPTH
<br /> DISrANCETO NEAREST-, WELL 1 `.ir Tftr.FOUNDATION
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<br /> ❑ .S SERPAGE-PITS N.uMseR-. -' " -"'''"G Wmix"- ^ '. �` "' ft `._i.DEPTH -•.: � "ft;
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<br /> s`iDISTANCE TO NEARESTWELL _ - ' _-. - .
<br /> I HEREBYCERTIFY THAT I HAVE PREPARED THISAPPLICATSON AND THE WORK W ILL DE DONE IN ACCORDANCE W lTR SAN 20AQ1.164COUNTY )� ,
<br /> ORDINANC£3 STATELAWS ANDRULESAND REGULATIONS OF SAN JOAQUINCDUNTY qr
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<br /> Il,y rz3 MINIMUM24 HOAR ADVANCE NOTICEREQUiRE FOR INSPECTION$..:PLEASECALL(209J 953 T697 rF y r
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<br /> DEPARTMEIIT U E ONLY '.,.�Fl � _'-y s-7;A ti 4 -'� t �•, ,
<br /> } Application Accepted By � : `"'"'" F es` '>�Dale. rP .�S.1'65 3 Area`� �-, i ,, Employee i D#
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<br /> rSFI4allnspectinBy w-- aw � <r --' 6, Date fi❑ SPECIAL PERMIT Approvedby
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