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t- ONSITE W 1`7EWATER TREATMENT-Sy('-NtM PE <br /> 5 �420 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEA LT.DEPARTMENT 304 E WEBLK-AVE -3"° <br /> FL—STOCK - 2 ISSUED 3 <br /> NON—REFUNDABLE PERMIT ALL(209. .53-7'09'1 R INSPECTIONS EXPIRES,1...EAR FROM DALE ISSUED <br /> (/. CITY/ZIP C/ <br /> JOB ADDRESS - <br /> �J,, <br /> /2l APN /" O's PARCEL SIO-' 9 <br /> CROSS STREET - - — <br /> OWNER NAME --rf)P 1 /V Ir/v `•7 - - .- PHONE M 4661—/ — 7e.2-3 -- Am <br /> OWNER ADDRESS / /� s CITYISTATEIZIP <br /> 1140 <br /> CONTRACTOR 4AD� J PHONE <br /> CONTRACTOR ADDRESS • CITY/STATEIZIP. IIA <br /> LICENSE -42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL-ItVFORMAT�ON Coordinate's X Y <br /> 4f or t <br /> ❑ . PERC TEST # BUILDING PERMIT# 27 tYL,LAND USE APPLICATION# `I <br /> TYPE'OF WORK: NEW INSTALLATION ❑ REPAIRIADDITION :.'❑ ENGINEERDESIGNED/ALTERNATIVE 1 <br /> ❑' REPLACEMENT ❑ DESTRUCTION '.'. <br /> INSTALLATION WILL SERVE: ESIDENCE ❑ COMNIEACIAL " ❑ OTHER <br /> NUMBER OF LIVING UNITS- NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> kw SEPTICTANK TYPEIMFGC-eAJeAf t-- CAPACITY Q _ galY #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS - r. <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST:..WELL t/ ft ,FOUNDATION = _ ft "PROPERTY CINE R <br /> ❑ LIFT STATION SIZE TYPE UMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> `LEACH LINES yIf LEACHING CHAMBERS #OF LINES � LENGTH OF LINES "r"(/ ft <br /> DISTANCE TO NEAREST_ WEL[. ^' FOUNDATION R PROPERTY LINE " ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ..ft-:FOUNDATION t ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ' ft <br /> I <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft ' LENGTH DEPTH ft <br /> DISTANCE TO NEA EST WELL ft FOUNDATION ft PROPERTY LINE ft. <br /> SEEPAGE PITS NuN1';ER WIDTH ft DEPTH 1�5 � ft <br /> DISTANCE TON AREST WELL,1F3�ft FOUNDATION 'v <br /> •ft PROPERTY LINE .J t <br /> 1 HEREBY CERTIFY THAT'I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY: . iq;: i:::':3."` <br /> MI MUM HOU ADVANCE NOT ERE UIRED FOR INSPECT NS;;PLEASE CALL:( O2 -)953-7697 <br /> Q : �.. <br /> SIGNED "S TITLE DATE <br /> e <br /> i �• — .$ }< :r _o r ,vt ;1' - mss•#'� " <br /> Al <br /> 41 <br /> r <br /> y. .,.9 <br /> e1Y.. <br /> DE ARTMENT YSE ON <br /> ApplicationoAccB', Date Area Employee ID# <br /> Final Inspe Date � ❑ SPECIA�RMIT A pr ved yCharacter pt of 3 Ft: PJt Sump Soil Character: !/ <br /> JCOMMEN"I'Sn 5 <br /> i a P <br /> PE SC Received hec Amount Date PePermit/ •[nvo ce#— 'Per it I'D39s <br /> Code INFO B Cash Remitted ,:-,., Service Reguest# <br /> 42.02.001 ONSITE WASTEWATER PERMIT <br /> 12/2272003 <br />