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j' IoW <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> :CAN JoAQU IN COUNTY ENVIRONMENT A LHF.A LTH DLPANTMLNI 304E WEBER AVE-3`'FL-S I'OCXTON CA 95202 - (109)468-3420 <br /> NON-REFUNDABLE PERMIT CALI,fn)953-7697 Fo INSPECTIONS E FIRE 1 YEAR FROM DATE ISSUED <br /> ;r. <br /> JOBADDRESSZ� C17YlZIP KV <br /> /y O� RC / 0 <br /> CROSS STREET APN PAELSIZE/!J <br /> OWNER NAME PHHONE/ <br /> OWNER ADDRESS CrrY/STATFIL{P <br /> CONTRACTOR — Cr PHONE <br /> CONTRACTOR ADDRLSS �/ CrrV1STATFIZIP lel.1jeAdfl1^� <br /> LICENSE 42 ElII <br /> C-36 OTHER NMHEREXPIRATTON DATE' <br /> WATER TABLE DEPTH: _ R GEOCRAPHICAL INFORMATION: Coordinates X <br /> ❑ PERC TEST(S) NII1FIBER LAND UsE APPLICATION N <br /> TYPE OF WORK: ❑ NEW INSTALLATION )w—r, REPAIR/ADDITION ❑ ENGINEER DESIGN ED]ALTERNATIVE <br /> O REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMENCIAL ❑ OTHER_ 1� <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS' - I NUMBER OF ENPLOYF.F.S: <br /> De <br /> ❑ SEPTIC TANK TYPF.MFG_ CAPACrry____ gal rr OF COMPARTMENTS ^ <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal N OF COMPARTMENTS \_^) <br /> ❑ PKC TX PLANT DISTANCETO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP r ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES �r LEACHING CHAMBERS J p OF LINES LENGTH OF LINES TIS it C <br /> DISTANCE TO NEAREST WILL--?—Oft FOUNDATION�ry R PROPERTY LINE �ft <br /> ❑ FILTER BED WIDTH R LENGTH _R DEPTH ft <br /> DISTANCFTONF.ARF_5T WELL - ft FOUNDATION_fl PROPER rY LIN�PAY1/ '^ I — 11 <br /> ❑ MOUNDED WIDTI1 R LENGTH R DEPTH RECEIVFD It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION J ft PROPERTY LINE nn R <br /> ❑ SUMPS WIDTH R LENOTH _ R [lT DEPTH l,l UM ft <br /> DISTANCE TO NEAREST WELL__ R FOUNDATION ft PROPERTY LINE ft <br /> -AN JOS\Ot1AT� <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH _ ._ft DEPTH w ccmnrcc R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PHOPERTY9.hIJFfi!"I:"_illc(;I.AITHDIVISICR <br /> SEEPAGE PITS WIDTH 3 R L> It DEPTH ft <br /> DISTAN'CETONEAMT WELL R FOUNDATION R PROPERTY LINE �� R <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORM.WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> 51"A I'E LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> NIMUM 24 HOUR ADVANCE NOTICE <br /> 7REQUIRED FOR INSPECTIONS-PLEASE CALL(70099)933-7697 <br /> SIGNED d � a TITLE, / !,40_" A%rw _ DATE 3 <br /> 1 <br /> 41Z-T it <br /> j 4P <br /> 01 <br /> i <br /> 1 <br /> DIEPAE ONL <br /> Application Accepted k�o p y e y <br /> Date /f✓)- �' Area � /�- Em to ee ID8 <br /> Final Inspection By. �,� Date �/Q3 ❑ SPEC I.PERMIT-Appto ed b <br /> Character or Soll b h or 3 Ft: PiUSump Soil Character: <br /> COMMENTS <br /> d� <br /> PESC Reeeived hoc Amount Dale Permit/ Invoke N Permil IDN <br /> Code INFO By Caah Remitted Service Request N <br /> Zile- <br /> 42111.001 <br /> 17/2,02 ONSITE WASTEWATER PERMIT <br />