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ONSITE WASTEWATER TREATMENT SYSTE- PERMIT SAN J45AQUIN COUNTY ENVIRONMENTAL HEALTH DEPA ENT FCROSNON-REFUNDABLE PERMIT 304E WEBER AVE 'FIRES lcroN CA 95201 - (209)468-3420CALL(209)953-7697 FOR INKPecnoNN S ESS 18if� G�T �Q � EXPIRES 1 YEAR FROM DATE ISSUED / y,�,r G /� CITY/ZIP � ef` �" j H EET Y I�Sr�,// T'E Ay4 ,I ,APN / 2 PARCEL SIZE �•3 "rvrn� eME �/1�(L orTT1.4 Lpe4yye mgEST/ r� �fPHONE�g J`'. -• �7-OCJDRESSI6o0 GA5T /VQI/�O/( �I pn� q "�♦♦ /�— CITY/STATE/ZIPRACTOR ��..'.�(��v /JNCLJ/ /f I H CT PHONE�p 4-19 CONTRACTOR ADDRESS E Q . R Y ��4 00 CITY/STATE/ZIP / (RISLO k. C�� / U' LICENSE ❑C-42 ❑C-36 OTHER NUMBER WATER TABLE DEPTH: 01 EXPIRATION DATE EOGRAPIIICALINFORMATION: Coordinates X y yr PERC TEST(S) NUMBER_ LAND USE APPLICATION# TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ REPLACEMENT El ENGINEER DESIGNED/ALTERNATIVE r ❑ DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYES: ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION R PROPERTY LINE It ❑ LIFT STATION Slz¢ TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES IF DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE fl ❑ FILTER BED WIDTII R LENGTH R DEPTH It C DISTANCE TO NEAREST WELL ft FOUNDATION R PROP IE It E3MOUNDEDMOUNDED WIDTH ft LENGTH -� R t DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPE N Yff ❑ SUMPS WIDTH ft LENGTH R DEPTHt DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R ❑ SEEPAGE PITS WIDTH ft LENGTH R DEPTH R DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 1 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 SAN JOAQUIN COUNTY. 1 1 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED TITLE OZ4l�A/G,i/c DATE /a -7 2-d3 01 J L G \G U rE :N DEPARTMENT USE ONLY 'Y ty� 7� ly`. Application Accepted By `J ' Date '7-Z.. �l�J Area •� a Employee,110 ---1_/� Final Inspection Date ❑ SPECIAL PERMIT-Approved by It/SD ��I Character of S Dept Ft: p Soil Character: COMMENTS �/ d a v PE "Received h" Amoanl Date Permit/ Invoice# Permit ID# Code INFO B ash Remitted Service Re Dest# Z ti -zf-- I RYL 43 ly------------- y 3S 42-01-001 ONSITE WASTEWATER PERMIT 12/2/02