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-C 1 L JU •L U <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E MAIN STREET-$70CK70N CA 9$202-(209)468-$420 <br /> NON-REFUND C LL 209 953-1 7 OR INSPECTION[$ EXPIRE 1Y F S O <br /> Joe ADDRESS — l <br /> CITY/ZIP <br /> CROSS STREET ILE N T <br /> PARCEL SIZE > <br /> OWNER NAME M1' SLt� >—d _ 1 <br /> - PHONE <br /> OWNER ADDRESS CITY/STAT P �l�1 <br /> CONTRACTOR `�y" l PHONE]O <br /> CONTRACTOR ADDRESS J, H�J ti ~ <br /> J I CITY/STATE/ZIP I I <br /> LICENSE 'XC-42 RC-36 OTHERA NUMBER EXPIRATION DATE vl <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: COOrdinatea X y <br /> PERC TEST X BUILDING PERMIT# LAND USE APPLICATION <br /> TYPE OF WORK: I NEW INSTALLATION --- REpA1R/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-0F-SERVICE SEPTIC SYSTEM IJ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE X COMMERCIAL ❑ OTHER �y <br /> NUMBER OF LIVING UNITS: rC^?�� / NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: �j X <br /> �p SEPTIC TANK TVPE/MFG y 16t,7:Vim+C CAPACITY 1 L �J g81 #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATIO ft PROPERTY LINE ft <br /> 1w FILTER BED WIDTH ( ft L G ft DEPTH ft <br /> I <br /> DISTANCE TO NEAREST WELL 1 ft FOUNDATION _ft PROPERTY LINE 5 17 ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE h <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE -ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> M�Ngtjo 24 H U V - AI Tla REQUIRED FOR IN IO S %g4SE CALL 209 953-7697 , <br /> r <br /> I TITLE' 1 DATE - .L <br /> SIGNED` — <br /> SEP p Eq <br /> -- \ A7iT'7FEIPT �Yl <br /> gpnlicatinn Accep Date _ Area Employee ID# !%�A <br /> Final Inspec8on ` r_ Date !� O SPECIAL PERMIT-Approved by i <br /> Character of Soil to Qpth of 3 Ft: PIS-amp Soil Character: <br /> COMMENTS I /". f 1AZ4'iE--'— Jn:ZAr-tom// <br /> PE SC ReceivedMh <br /> Amount Date Peri Invoice f Permit IDD <br /> Code IN77 <br /> FO B Remitted Service Re uesty 2 r <br /> 700 <br /> 42-Ot <br /> 15 0 + 0 - 2700 Y 0 - 6 x O NSfTE WASTEWATER TRTMNT SYSTEPERMIT <br /> 9/21110 <br />