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3 ONSITE W�STEWR rTREATIVIENT,SYSTEM PERMIT:'" rk
<br /> ag:. S SAN=•1�-O.AQUIN GOUNTY ENVtRONMENTAL'HEALTIi"DEPARTM! +#`R'+'• 304 E WEBER AVE 3 FL :STDCI000N L 1202 -(209)4683420
<br /> CAL(:209,953=7697:POR INSPECTEIONs EXPIRE51 YEAR PROM�DATE ISSUED
<br /> ON;REFUNDABLEPEAMIit ?__ ---, _ _
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<br /> PARCEL SIZE 1� E �
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<br /> I DOWNER NAME +-, �^ _ kJ I C.1 ( "ri�r��+P+ ^�-i.vfrF -r- " .• PHONE
<br /> OWNER ADDRESS -"�'� '�- """' '^ +° }""f'"' - — CITYISTATEIZIP. �
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<br /> a CONTRACTOR PHONE
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<br /> s.k:) a CONTRACTORADDRESS C] c•1 •* CITY7$TATEIZIP .(I
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<br /> '%' t-LICENSE -r'❑CMZ ❑C 36 . OTHER �' -J°+" , -' NHMBFR� -- � EXPIRATION DATE
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<br /> . .WATER TABLE DEPTH
<br /> ,.--•� 'r ft ,GEOGRAPHICAL INFORMAI:ION COOrdlRat¢S�X ='+•• --•c Y
<br /> ;;PERGTEST 'BUILDING'=REKNIT# jn +K LAND USE FAPPI;ICAT[ON;#PA
<br /> wvTYPE-OF.WORK•} ❑p.:�NeW lrsrALLATION'; .r >'.-o�.t D,r_}AevAiRIADDrr10N .y, LIv.ENG1NEER DESIGNED(ALTERNATIVE
<br /> irn �1ii+i;dPa P:i1"O:. EPLACEMFNT,iSr'F•a<. ,.t.,:. ..F'-...h. �k- .-"rte k1❑ ::DESTRUCTION
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<br /> Y' :1NSyT�ALLATIONWILL SERVE ❑-REsilieivcF --" re ❑ COMMERCIAL- .F„ *_A.
<br /> ❑ OTHER '� "
<br /> - NUMBEROP LIVING UNITS - '-tib - ^'t• - NUMHER OFBEDRDOMS:" s%'k""` •''tNUMB£R OF EMPLOYEES: -• ; ' �" 'F
<br /> V❑r,SEPTIC TANK TYPEIMFG +` _ "� '; r 1 �CAPACTTY gal_i,"#OF COMPARTMENTS
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<br /> 'f ❑r, 'GRE.45E 3RAP,A TYPEIMFG. - �CAPACfIY gel #OF COMPARTMENTS '-
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<br /> .❑''�PKG TX PLANT -4 DISCANCETO NEARFSI':9'i WELL! � R.�iFOUNDATION- -:'kR., "PROPERTY LINE= ft
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<br /> ? ❑. L117f'STATION' SIZE PE TYOP PUMP ❑ SAND OIL SEPARATOR(ENCLOSEDSvSTEM
<br /> 1❑ LEACH LINES !'-_❑'.LEACHINC CHIAINBERS� ^h'S wii,-'} -'""'ar:-" -#OF°LINES '�"j"k s LENGTH OF LMES' "• -
<br /> ;,, DAT
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<br /> DISTANCE TONEAREST WELL i't
<br /> - ft DATION PROPERTY.LME ,ft
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<br /> ❑;'FILTER BED -.,WIDTH ft,a,;LEHGTH ,1 -- ft`.� .DEPTH - ft
<br /> t ,DISTANCETD NEAREST WELL `ft2�FOUNDATION � ft „ ;�PROPERTY LINE'
<br /> 1 ❑ .MOUNDED'- WIDTH I it LENGTH ft "DEPTH ft
<br /> .~. fL, ft, ME ... .. ft
<br /> !I � DISTANCE 70 NEAREST WELL�' � �ff FO PROPERTY L
<br /> ❑ 'SUMPS - - •-..WIDTH - ft LENGTH ft DEPTH _- ft
<br /> DISTANCETONEARFST WELL ft FOUNDATION ft PROPERTY LINE ft
<br /> _ ❑ DISPOSAL PONDS WIDTH ft�ILENGTH ' 'r"• y i,-,,:.: 'r` ft' DEPTH ft
<br /> DISTANCE TO NEAREST WELL: .ft ,FOUNDATION, ft PROPERTY LINE ft
<br /> C1SEEPAGE PITS NUMBER - WIDTH _ ft DEPTH ft
<br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LME ft
<br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQU IN COUNTY W
<br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY,
<br /> e4r[ (MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)997-7697
<br /> l SIGNEQ f �' �� 'l-lam` �__ TITLE f_`"` -�l f � DATE `-'�•�
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<br /> DEPARTMENT ySE NLV
<br /> Application Accepted By _��`"" Ir" -•-• Date f �f U-S Area Employee ID#
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<br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by
<br /> 1 Character Of Sail to Depth of 3 Pt: PltlSump Soil Character*
<br /> COMMENTS
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<br /> PE SC Received her,!Wk Amount Permit! (novice'# Permit[D#
<br /> Date
<br /> Code INFO By Cash „Remitted Service Request#
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<br /> 42-02-001 ONSITE WASTEWATER PERMIT
<br /> r 12R2J2003
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