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Page 1 of 1 ONSITE WASTEWATER TREATMENT SYSTEM PE SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-', NON-REFUNDABLE PERMIT CALL 209 953 7697 FOR INSPECTIONS EXPI JOB ADDRESS ` VC 'ZZZ\ CITY/ZIP 7 �I p� �p CROSS STREET 7 V✓\ L, 1^AP/N rOO L — �02k� 4M Sy OWNER NAME �.J1=.�N.O.^>J �� YI CAI `fel/ / '1 PHONE OWNER ADDRESS CITYISTATEIZIP CONTRACTOR t wT C� C� ~�Y CU 1^5 T PHONE �- CONTRACTOR ADDRESS 1 I S 45 t CITY/STATE/ZIP (46 LICENSE .CA2 C-36 OTHER _ NUMBER c�y7rz EXPIRATION DATE WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X PERC TEST # BUILDING PERMIT# — 0-30C) AND USE APPL TYPE OF WORK: NEW INSTALLATION REPAIR/ADDMON G E REPLACEMENT - DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE XCOMMERGAL OFIFi" ❑ OTHI NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMB SEPTIC TANK TYPEIMFG — CAPACITY gal O GREASETRAP TYPE/MFG CAPACITY _ gal DISTANCE TO NEAREST: WELL ft FOUNDATION It ❑ LIFTSTATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SANDOIL lc� LEACH LINES C LEACHING CHAMBERS #OFLMS-121-- LEN( DISTANCE TO NEAREST WELL ft FOUNDATION ft ❑ FILTER BED WIDTH IT, LENGTH ft DEPT DISTANCE TO NEAREST WELL It FOUNDATION ft ❑ MOUNDED WIDTH II LENGTH It DEPT DISTANCE TO NEAREST WELL it FOUNDATION It ❑ SUMPS WIDTH _ It LENGTH It DEPT DISTANCE TO NEAREST WELL R FOUNDATION ft ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPT ,J/ DISTANCE TO NEAREST WELLft FOUNDATION IT Ill SEEPAGE PITS NUMBER .41 WIDTH -3 IT DEPT DISTANCE TO NEAREST WELL ft FOUNDATION fl I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. --------1111 MINI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPE^CTIO S-PL ASE CALL(20' SIGNED TITLE 5PG�1��5 file://C:\Documents and Settings\mescotto\Local Settings\Temp\DMCI\D00\I.JPG 8/22/2012