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,an <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 301E WEBER AVE-3"FL-STOCRTON CA 95202-(209)A 410 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7 97 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDREtt L Cmalp J �� <br /> w` `(fi 5 <br /> CROSS STRBET G APN`W—y,V �S PARCELSIEE/?_ > <br /> OWNERNAME ��(J J (/Q�/3.�A/f PHONE d;0Z 3 <br /> OWNERAODRESS CITY/SYATTIZiP <br /> CONTRACTOR <br /> Px.n'e fgu <br /> CONIAACI'ORAODRFSS Clil,/SI•A•fE/ZIT <br /> LICENSE 42 OC-36 OTHER NOMBEa ExpimnoNDATE <br /> WATBRTABLEDEPIN: fl GEOGRAPHICALINFOR LVIJON: CBSrdlnele5 X Y <br /> O PERCTEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDDION ❑ ENGINEPADESICNED/ALTERNATIVE <br /> 10( REPLACEMENT lkm C DESTRUCDON ) O <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> Trr���rrr NUMBEROF LIVING UNITS: /NUMSEROPBEDROOMS: NUMBEBOPEMPIAVEES: <br /> SEPTIC TANK TYPFJMFG f2- CAPACITY PI #OFCOMPARTMEMS� <br /> ❑ GREASE TRAP T'PE/MFG CAPACITY PI NOFCOMPARTMENTS <br /> ❑ PRG TX PLANT DISTANCETONEAREST: WELL fl FOUNDATION fl PROPERTY LINE fl <br /> O LIFT STATION SITE TYPEOFPUMP ❑ SAND OIL SEPARATOR(ENc1.OSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHINCCHAMBERS #OFLINES LENGTH oFLDIES fl <br /> DISTANCETONEAREST WELL ft FOUNOATION fl PROPERTY LINE fl <br /> O FILTER BED WIDTH ft LENGTH B DEPTH ft <br /> DIWANCETONEARFST WELL fl FOUNDATION ft PROPERTY LINE fl <br /> ❑ MOUNDED WIDTH ft LENGTH I DEPTH p <br /> DIBTANczm NFAREBr WELL R FOUNDATION It PROPERTY LME ft <br /> ❑ BUMPR WIMR ft L;NDTN R DEPTH ft <br /> DISTAMCETO N[AREST WELL fl FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WmTX ft LENGTH 8 DEFTH ft <br /> DISTANCETONEAREST WELL fl FOIMDATION ft PROPERTY LME fl <br /> ❑ SEEPAGE PITS NMIBER WIDTH ft DEPTH ft <br /> DIEEANCETONEAREST WELL fl FOUNDATION ft PROPERTY LME fl <br /> I HEREBY CERTIFY THAT i HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUMMHOURADV CENOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-0697 <br /> SIGNED TITLE <br /> DATE <br /> N <br /> -' <br /> fAPCharxter oFSnnil to PADRnTteMEN. U/SE LY� A. <br /> -EmpWyeIDN <br /> M�_ �� <br /> Plkatlon A 13 SPECIAL PERMIT-AppmTNI by <br /> .131: PIUSump&HC"mcRr. <br /> COMMENTS <br /> / <br /> PE SC RmeiyIdeeLW Amount Po <br /> rmW IBVDItthlmkigf <br /> Cade INF. B CBnh RDIMEel"NI Se,k:R ut# N <br /> S a 6 L4 S 9 <br /> U-02-0DI <br /> IN1/!W3 ONSITE WASTEWATER PERMIT <br />