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10'V ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP <br /> � ENT 304 E WEBER A VEs�FL-ST'OCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE <br /> JLPERMIT /C� L(209)953-7697 FOR INSPE('TIONS �EXPIRES`I YEAR FROM DATE ISSUED <br /> LO <br /> JOB ADDRESS 1 T 1 I S• � /�� CITY/ZIP I /T KHI0./G• L IlNy y <br /> CROSS STREET C"—rff-F- ROM) APN 73/ PARCEL SIZE4S nP <br /> ) <br /> 0 <br /> NOEp�j <br /> / _ �9C Yrt VOWNERNAME <br /> OWNERADDRESS ' ILS CITY/STATE/ZIP /''7 / <br /> CONTRACTOR �/l.I Q ('t 1 3 n c'*,sy-N 'e'A- 10 C I N C • PHONE '3& <br /> CONTRACTOR ADDRESS /' C^1� CITY/ST <br /> 'A <br /> 1TE/ZIP <br /> LICENSE L3 C-42 C-42 ❑C-36 OTHER J T NUMBER OV 4- EXPIRATION DATE <br /> WATER TABLE DEPTH: // it GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> Z <br /> PERC TEST(S) NUMBER LAND USE APPLICATION# C3nn <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE 1 <br /> ❑ REPLACEMENT ❑ DESTRUCTION' v' <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS D <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS -, <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL it FOUNDATION it PROPERTY LINE it <br /> ❑ LIFTSTATION SIZE TYPE OF Pump ❑ SAND.OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES it <br /> DISTANCE TO NEAREST WELL R FOUNDATION 1 it PROPERTY LINE ft . <br /> ❑ FILTER BED WIDTH it LENGTH H DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION—11 PROPERTY LINE it <br /> ❑ MOUNDED WIDTH 11 LENGTH 11 DEPTH Il <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE it <br /> ❑ SUMPS WIDTH ft LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPTH it <br /> DISTANCE TO NEAREST WELL it FOUNDATION It PROPERTY LINE it <br /> ❑ SEEPAGE PITS WIDTH it LENGTH it DEPTH it <br /> DIBTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> f. HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 Q L ? <br /> SIGNED TITLE S/18x1" L Nli/A1S.1 IL- DATE '/ ✓ �> <br /> I .mil <br /> • aaa N u' <br /> 900 <br /> P.pP,S <br /> T � 1 <br /> DEPARTMENT US ONLY ♦ / <br /> Application Accepted. Date n > Arca Employee lD#_10a <br /> Final Inspection By zukDatev� ❑ SPECIAL PERMIT-Approved by / <br /> Character of Soil to De th oS�Ft: it Sump Soil Character: _ % <br /> COMMENTS it L P - Z / <br /> _ ,. � ., H _ may' ' � ' r, 'z.t✓. <br /> IF <br /> PE SC ReceivedAmount Date Permit/ Invoice# Permit lD# <br /> Code INFO B Cesh Remitted Service Re nest# <br /> 3'F6(. 23 S <br /> 42-01-001 ONSITE WASTEWATER PERMIT <br /> 122102 <br />