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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT R" ��SAN JOAQUIN COUNTY ENVIRONMENTAL HEA10 4EPARTMENT 304 E WEBER AVE-31°PI"['xTON CA 95202 - (209)468-3420 I NON-REFUNDABLE PERMIT CALL(209)953_7647 FOR�FNSPECI IONS EV '�S I YEAR FROM DATE ISSUED JOB ADDRESS „ - CITY/ZIP �� `'. `7 CROSS STREET ; „ '� I I; M ` APN -' PARCEL SIZE I C�` c 1 OWNER NAME �•„! I `c=am ..1 } \ � �__- -,i,a ( /1 �- •� PHONE [ i A OWNER ADDRESS 5 �. ' _ CITYISTATE7ZIP CONTRACTOR PHONE �Z y 1 CONTRACTOR ADDRESS _1_ �� 1-y. _- ' i+..; CiTY1STgTF1ZEP ]j,ry•"•' I� ( - •L#L LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE +E WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: ❑ NEW INSTALLATION ❑ HE PAIAIADDITION ❑ ENGINEER pESICNED!ALTERNATIVE Z! REPLACEMENT . ❑ DESTRUCTION # fff^^^ INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NDMBER OF EMPLOYEES: »- ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COM PARTMENTS ❑ PKC TX PLANT DISTANCETO NEAREST: WELL 0 FOUNDATION f< PROPERTY LINE fl ` ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) I ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATm ft PROPERTY LINE ft - ❑ FILTER RED WIDTH A LENGTH fl DEPTH R y !} DISTANCE TO NEAREST WELL It FOIINDATtON fl PROPERTY LINE R ❑ MOUNDED WIDTH ft LENGTH L DEPTH fl DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft f Cl SDMP$ WIDTH ft LENGTH ft DEPTH ft DISTANCE TO N EAREST WELL ft'FOUNDATION ft PROP>RTY LINE ft r ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It r k { }a DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE IT 1,I ]}i q ❑ SEEPAGE PITS NUMBFR WIDTH R DEPTH ft -* r DISTANCE TO NEAREST WELL It FOUNDATION fl PROPERTY LINE fl 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ; P` ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. NfIN1iM URI 24 Hf IIIR ADV,\NC'E NO'I'I CF;REQUIRED FOR fN:5 PEC1101'ti-PLEASE CALL f2U4145;_7697 + SIGNED - r`_--__"_` TITLE DATE ��-- I , Fi TI l l TTTT i - I fl a Im- - _±ffil %-.. DEPARTMENT USE ONLY Application Accepted By '�'`'^""— �- Date ' I Area Employee ID# Final Inspection By Date ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: - COMMENTS PE SC Received %Check,41-1 Amount Date Permitl {. Code IrcFo B Cash Remitted Service Request N Invoice# Permit IM 1 212 212 003 ONSITE W ASTEW ATER PERMIT'