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ONSITE WASTEWATEP "'REATMENT SYSTEM PERMIT <br /> Ran SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEM \ 304 WEBER AVE J'PL-STOCNTON CA 95209)4611-3/20 <br /> NON-REFUNDABLE PERMIT CALL 209 953--7697 FOR INSPECTIONS EXPIRES 1 YEAR'^FROM DATE ISSUED <br /> JOBADDREss q UC f'\IV'1fIV\("C Ct(� Clrv/Zle �ICC}7�C✓` �1' be <br /> CROSS STREET ��1( �� i �- �(.� ( '�Ilb[3 APN ��`I �� /�� �� PARCELSIEE DC <br /> 7OWNERNAME ( I/f 1 I I3 + SAA' 1:J( C (Yf1.'.•r/ PHONE flWY7S <br /> I <br /> 7c <br /> OWNERADDRESS (� C I 1.• f / CM/STATE/ZIP ) /. .• P. I. ` I <br /> CONTRACTOR F I i ( ,3'T l./ r .^ '� .'-( /I r(' PHONE <br /> CONTRACTOR ADDRESS I I ".l.,r. (.!Ii CITY/STATLTAP C /•�. r / <br /> LICENSE ❑C42 13 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICALINFORMATION: CoOTNDafb X Y <br /> ❑ PERC TEST N BUILDING PERMIT# LAND USE APPLICATION# 'I' <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIWADDITION ❑ ENGINEERDMIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> Rana INSTALLATION WILL SERVE: ❑ RESIDENCE - EICOMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBEROP EMPLOYEES: <br /> ❑ SEPTIC TANK TYPFJMFG CAPACITY Sol #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY IPI #OFCOMPARTMENTS <br /> ❑ PKG TX PLANT DIsrANCETONEAEEET: WELL ft FoumAT1oN R PROPERTY LINE R <br /> ❑ LIFT STATION Slav TwEOFPuMP O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LME$ LENGTH OF LINES R <br /> r <br /> DISTANCC TO NEAREST' WELL R FONJDATWN R PROPERTY LINE R <br /> ❑ FILTER BED WIDTH It LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LME R •v� <br /> ❑ MOUNDED WIDTH ft LENGTH R DEPTH R <br /> DISTANCE TONGRL41' WELL R FOUNDATION fl PROPERTY LME R y <br /> ❑ SUMPS WmTN ft LENGTH R DEPTH R <br /> DISTAYCEmNEARSIT WELL ft FOUNDATION fl PROPERTY LME ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH R DEFTH ft n( <br /> r DISTANCETONEAREST WELL R FOUNDATION fl PROPERTY LME R <br /> 1 <br /> ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH ft R <br /> DISANCETONEARBSr WELL R FOUNDATION ft PROPERTYLME R <br /> BTR I HEREBY CERTIPY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL HE DONE IN ACCORDANCE WITH SATS JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES ANO REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQU I RED FOR I NSPECTIONS-PLEASE CALL(209)953-7697 + ' <br /> slcnE�� (C'd 9 �j TITLE -#T'((--_f<.I DATE 1l7- ll-OI/ <br /> tz <br /> a <br /> I <br /> i I <br /> 1 <br /> l <br /> � Y <br /> T C <br /> "j DEPARTMENT US O LTV <br /> Application Accepted By ' Date `'�U7/ Area Employee ID# (J7 'i`1 <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PIUSump Sall Character: <br /> COMMENTS <br /> PE SC Received Amount DR[ PermiU Invoice# PermltlD# <br /> Cod< INFO BY If Carh Remitted / ServlccR ueat# <br /> 5-IS <br /> P-OO 3 <br /> - aLp2-001 ONSITE WASTEWATER PERMIT j <br /> 2003 <br />