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�i <br /> t <br /> G ► i <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> 3 SAN JOAQUIN COUNTY LN'a'IRONMEN'TAL HLAI,TH DEPARTAI ENT 304 F,WEBER AIT-3 FL-STOCK701CA 45202 - I:0u1.t 6n.3420 <br /> f NON-REFL NDA BLE PERMIT CAI-LiZ04)053-7h97 FOR INNPECT1ONc EXPIRES F YEAR FRONT DATE ISSI,'ED <br /> .. <br /> JOB ADDRESS CiTYIZIP iy - <br /> J _ <br /> CROSS STREET I, APN I` 'I :1; {•_ M1 PARCEL$iZ.E <br /> OWNER NAME r!/'r /i v PHONE <br /> P1 } <br /> OWNER ADDRESS J f CITYl$TATEIZIP _ 1. �� t <br /> CONTRACTOR 1, 'p i 1" •.CC'! PHONE — f <br /> I CONTRACTOR ADDRESS CITYISTATEJZIP <br /> Fl LICENSE ❑C-42 ❑C-36 J OTHER Numm:R EXPIRATION DATE, <br /> WATER TABLE DEPTH: eR f GEOGRAPHICALINFORMATiON: Coordinates X Y <br /> 1 {� PERC TEST # J. BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGIN EER DESIGNED fpLTERNATIVE <br /> A I ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> I^ NUMBER OF LIYINC UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> I !eF} ❑ SEPTIC TANK TYPEIMFO CAPACITY ,gal #OF COMPARTMENTS <br /> i ❑ CREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> i <br /> ❑ PKG TX PLANT DISTANCETo NEAREST: WELL ft FOUNUAT ION ft PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM} <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #CF LFNES LENGTH OF LINES ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> Cl FILTER BED WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft rOu NMATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH Ft LENGTH R DEPTH It <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> [ter ❑ SUMPS WIDTH R LENGTH ft DEPTH ft <br /> {t}j' DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ .SEEPAGE PITS NUMBER W1DTR R DEPTH h <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> -+ 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WI LL BE DONE IN ACCORDANCE WITH SAN JOAQU IN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> 1ltyyy+++���.. NI IN���f 2424 AOR DS�AN NOTICE REQUIRED FOR INS PECTIONS-PLErL44•,/C�ALL IInPI 953-Tfi97 ,.} <br /> SIGNED V.=,!'.tJ r / r ,j f TITLE .Y_ ,Z`�- DATE <br /> F + <br /> t <br /> r-i 77U,171V <br /> F i r <br /> c I <br /> t4MFN TAP <br /> -. <br /> .. i .._. _ H f V7F wmow <br /> i <br /> F1 <br /> V 1 I <br /> i <br /> = DEPARTMENT USE E}NLY <br /> Date F <br /> Application Accepted By ?,/i%� Area Employee IDR <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump SUR Character: <br /> COMMENTS <br /> PE , <br /> Received '-Ghee klll�' Amount Date Permitl Invoice# Permit ID# <br /> Cade INFO B Cash Remitted Service Re uesi B <br /> F--� rlf-.r/ <br /> 42-o2-007 ONRITF WASTFW ATTR PFRARIT <br />