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ONSITE WASTE=A TREATMENT SYSTEM PE,,, SAN JOAQUIN COUNTVENVIRONMENTALHEALTII DEPARTMENT 304 E WEBER AVE -3""FL-a KTON CA 95202 - (209)46&7420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Q �r,`c y JOB ADDRESS ' C�V J� TNF,F, CITY/ZIP 1-'U I / * m G 063-7-7C>- 7o ISS. '/Z o CROSS STREET PA" i-AAA)r-.��r✓. APNPARCC'/EE./LL SIIZE p OWNER NAME: -WDIE F-/T/ t✓ rJAAI PHONE f{:'sem a -/�� OWNER ADDRESS ff�C. '1 ..�1L IZ��Ur r�,f CITY/STATE/ZIP L-1WpC%,J7CAj/0/5 36 CONTRACTOR D ILL4 Yl M IJs-'T,,IT Y PHONE /�''�� -r•1 13 CONTRACTOR ADDRESS ' v' -Y( I rJU CITVISTATE/ZIP "4 C/1 2- LICENSE ❑CA2 OC-36 I ]]OTHER NUMBER EXPIRATION DATE w WATER TABLE DEPTH: Il GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST(S) NUMBER LAND USE APPLICATION# PA TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE O REPLACEMENT ❑ DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNI'T'S' NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SIA''I IC"TANK I I'l/MbU _ CAI'A('I'IY__ gill 11 UP C OMPARIMENTS ❑ GREASE TRAP IYI'P:/MFG CAPACI'T'Y gal #til'COMPARTMENTS ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION R PROPERTY LINE R ❑ LIFTSTATION SIZE. TvPE:OFPUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH of LINES R DISTANCE TO NEAREST WELL. R FOUNDATION R PROPERTY LINE R ❑ FILTER BED WIDI'B Il LENGTD ft DEPTH ft DISTANCE TO NEAREST WELL R FOUNDATION Il PROPERTY LINE R O MOUNDED WIDTH R LENGTH R DEPTH R DISTANCE TO NEAREST WELL III FOUNDATION Il PROPERTY LINE R ❑ SUMPS WIDT11 R LENGTH ft DEPTH ft DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH R DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS WIDTH R LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R I HEREBY CERTIFY THAT 1 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 COUNT\'. MINIM UM 24 HOUR ADVAN TRIED FOR INSPECTIONS-PLEASE CALL(209)953-7697 �n SIGNED TITLE P42'T`f GN/C-f-' DATE j i' 7. n o. A Ul -._ — rL M.po FlETT I DEPARTMENT EApplication Accepted oy - - .Date 9 � Employee ID#Final Inspecti By Date � L PERMIT-Approved by Character of Sol TIYSept M3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Permit lD# Code INFO B Cash Remitted Service Re u p 1� 60q 42-01-001 1212:12 ONSITE WASTEWATER PERMIT