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ONSITE WAST WATER TREATMENT SYST�"PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEA_LTI{DF ..MINT 304 E WEBER A' kit FL-STocKron CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT I 1 /^ {'CALL(209),1953-7697 FOR INSPECTIONS —EXPIRES 1 YEAR FROM DAT E ISSUED Jon ADDRE2.7 7 W SS I G ( T- r (,{ CITY/ZIP �1 1 �7 M CROSS STREET 1+`V� APN3�-a•7o~O ( PARCEL SIZE d OWNER NAME Lji 7 IVB PirONK 3 36 y OWNERADDRESS 71�� 1�Ct -� CITYISTATE/ZIP ,A'1Y1Y7 (_.J'"1 ! , y CONTRACTOR , y lio l SSo(- _ PHONE. 6167~ 70 CONTRACTOR ADDRESSq�Qa V 115 CITWSTATEIZIP LICENSE 0 C-42 ❑C-36 OTHER NUMBER ExPIRATIoN DATE, WATER TABLE DEPTH- ft GEOGRAPHICAL INFORMATION: Coordinates X Y PE RC TEST(S) NUMBER LAND USE APPLICATION# TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT ❑ DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: Numm.R OF BEDROOMS: NUMnFR OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY - gal #OP COMPARTMENTS 7I ❑ GREASE TRAP TYPE/MFG - CAPACITY gal #OF COMPARTMENTS ❑ PKG TX PLANT DISTANCET'O NEAREST: WELL.: It FOUNDATION Il PROPERTY LINE Q ❑ L1 FT STATION SIZE; TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WF,I:I: fl FOUNDATION R PROPERTY LINE }� ❑ FILTER 13ED %vur1'11 1t LENG'ria ft DEPTII ft DISTANCE TO NEAREST WELL ft FOUNDATION ft . PROPERTY LINE ❑ MOUNDED WIDTH R LENGTH ftpgPTII ft DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE .�. It ' ❑ SUMPS WIDTH ft LENGTH ft Mimi ft J I DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ® DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE,TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ' ft I HEREBY CERTIFY THAT 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 5AN JDAQUIN COUNTY. i11 NIM1 UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INS��PE,_C�TIO/�NS—PLEASE.CALL(209)453-7697 62 6 SIGN4� DATE .,� .T I �3z- -L1A1E ROAD h 7 ' �6 'W. t rtr s � 0.31ACS.-NET P/C 1 It= �� ( � � r o .49 AC. ` O i ,,TA 1 0 L04 Ac. CO- O � MA) J SAN 40.-lu VA ! r I„ r, . a 82 AC. ENVIA04 IQ- -A f° Q HEALTH r O N Application Accepted By Area y7 Employee ID# 9� Final Inspection By Date SPECIAL PERMIT-Approved by �� { Character of Soil to Dep of 3 Ft: it/ ump Lit Character: `1 " COMMENTS f r 1 r PE SC ReceivedCheck#/ Amount Dale Permit/ Invoice# Permit ID# Code INFO B ash Remitted Service Request# iz 42-01-001 1 t ' lD�iw 1� 1212102 ONSITE WASTEWATER PERMIT I