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ONSITE WASTEWATER TREAtMENT SYSTEM PE '1/ <90 SAN JOAQUIN COUNTY ENVIRONMENTAL HR EALTH DEPARTMENT l '�F, NON-REFUNDABLE HERMIT 304 E WEBER AVE-3""FL-STO(MOAY ( CALL(209)953-7697 FOR INSPECTIONS 2 a6e-34zo JOB ADDRESS - I EXPIRES 1 YEAR FROM DATE ISSUED CITY/ZIP CROSS STREET _ �1 "-"•-+.�.�a _ i- APNQ) a— _ 1 Q� D OWNER NAME Pn KCEt.SIZE�Q o rte'-t ',,e� Hr�,,�-+1+�}•as B -030223 OWNERADDRESS- !`/ �/—y`�--� IfOVF_-��1R 17 CITY/STATE/ZIP CONTRACTOR �— PHONE _lynfw7 CONTRACTOR ADDRESS ' CIT}'/STATFIZIP I LICENSE ❑C42 ❑C-36 OTHER - - NUMBER EXPIRATION DATE. CJ-I I WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X ❑ PERC TEST(S) NUMBER_ Y — LAND USE APPLICATION# TYPE OF WORK: A( NEW INSTALLATION ❑ REPAIWADDITIONETt 1 ❑ REPLACEMENT ❑ ENGINEER DESIGNED/ALTERNATIVE ❑ DESTRUCTION _ h INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: __ NUMBER OF BEDROOMS: 1 _ NV MB EROF EMPLOYEE$; SEPTIC TANK TYPE/MFG G4/l�reo1 CAPACITY #OFCOMPARTMENTS � — O� Ral a n O CREASE TRAP TYPE/MFG CAPACITY � gal #OF,COMPARTMENTS ¢_ ❑ PKG TX PLANT DISTANCE To NEAREST: WELL -tl FOUNDATION t3 PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP` Q SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES O LEACHING CHAMBERS Q— DISTANCE OF LINES LENGTH OF LINES fti DISTANCE TO NEAREST WELL 72CJO fl FOUNDATION 7 (O it PROPERTY LINE S 1 Il , ❑ FILTER BED WIDTH I1 LENGTH i it DEPTH ft r DISTANCE TO NEAREST WELL -ft FOUNDATION R PROPERTY LINE ft O ❑ MOUNDED WIDTH ft LENGTH it DEPTH �- ft I 1)MTAIIICE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft y DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDrH fl LENGTFI it DEPTH it DISTANCE TO NEAREST WELL fl FOUNDATION ft PROPERTY LINE. fl p ff SEEPAGE PITS WIDTH p 11 LENGTH ft DEPTH OZ.S I R DISTANCE TO NEAREST WELL "> -LOO ft FOUNDATION 7 Ib ft PROPERTY LINE > S ft I HEREBY CERTIFY T'HA-r I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN.JOAQUIN COUNTY ORDINANCES. STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALI.(209)953-7697 SIGNED ' \ _ Y "�'-� 4J TI'FLF. -)()(1 DATE�j�� —O I o 0 - I 0 1 — — 1 AR_ I , or 6l G H AL C Ntil 1 Kvt 0I tta %V 044 .� DEPARTMENT USE ONLY Application Acceplt`BRY" Final Inspection _ Dale -D L 11 SPECIAL PERMIT-Approved by Character of Soil to hof 3 'f: Pit/Sump Soil Character: COMMENTS PESC Received Chec Amount s PermiU j Code INFO By ash Remitted to Service Request# Invoke# Permit ID# �e 111 11.7 - loz 32,0 Th 910z, I'S \"~,... .