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Li OrmEn <br />NUMBER OF EMPLOYEES: <br />I COMMERCIAL <br />NUMBER OF BEDROOMS: <br /> <br />INSTALLATION WILL SERVE: liC4 RESIDENCE <br /> <br />NUMBER OF LIVING UNITS: <br />ft <br />gal SOP COMPARTMENTS__ <br />gal S OF COMPARTMENTS <br />ft PROPERTY LINE <br />CI SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />SEPTIC TANK TYPE/MFGK./.J5h 4 1151fr <br />GREASE TRAP TYPE/MFG <br />DISTANCE TO NEAREST: WELL ft <br />LIFT STATION SIZE TYPE OF PUMP <br />FOUNDATION <br />PKG Tx PLANT <br />CAPACITY <br />CAPACITY <br />BUILDING PERMIT* LAND USE APPLICATION # <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />CITY/STATE/ZIP ea:4 rA— 0- <br />PHONE jag <br />CYISTATE1ZW&44 c c 32 <br /> PHONE o4- 364 -3-0? 7 <br />Application Accepted By <br />Final Inspection By _ <br />Character of Soil to <br />COMMENTS <br />ii Vie <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN 40AOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STocicroN CA 95205- (209) 488-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE iSSUED <br />JOB ADDRESS i a€1.5a cfryizi, <br />CROSS STREET 4//;04' At411 <br />S4841.2rie rak tyyt p OWNER NAME <br />OWNER ADDRESS _p_o 42-6 <br /> <br />ENGINEER DESIGNED /ALTERNATIVE <br />DESTRUCTION <br /> <br />REPAIR/ADDITION <br />OUT-OF-SERVICE SEPTIC SYSTEM <br /> <br />NEW INSTALLATION <br />REPLACEMENT <br /> <br />X LEACH LINES F. LEACHING CHAMBERS 4 OF LINES <br />DISTANCE TO NEARESTWELL _100 ' It FOUNDATION 50 1 ft PROPERTY LINE /00 1 ft <br />LENGTH OF LINES <br /> <br />DEPTH ft FILTER BED WIDTH ft LENGTH ft <br />It PROPERTY LINE ft DISTANCE TO NEAREST WELL ft FOUNDATION <br />MOUNDED WIDTH It LENGTH _ ft <br /> <br />DEPTH <br />ft PROPERTY UNE DISTANCE TO NEAREST WELL ft FOUNDATION <br />WIDTH _----.. ft LENGTH ft <br /> <br />DEPTH <br />It PROPERTY LINE DISTANCE TO NEAREST WELL ft FOUNDATION <br />DISPOSAL PONDS WI0TI4 ft LENGTH ft DEPTH <br />ft ft PROPERTY LINE <br />ft DEPTH tP5 ft <br />S ft PROPERTY LINE /oat tt <br /> <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 <br />SIGNED TITLE DATE <br />4 ta. I <br />1161110111111111111 „ 1 , <br />IIIIIIIIII it 0 MN l'' I <br />1 <br />1111•1111111MINO 111"- <br />Inmommum 111111111111111111111111111011P9111, - 4,4 I V limmolimum 11111111111111L,L.114111_111rldJAPill <br /> <br />En 111111111111111M11411"1 <br />illifilla 1111111111111005111111111 <br /> liasuggplup ,? ' ,,, <br /> ,,,Area ? 99-- EmPI°Yee D#----i- <br />t I r o SPECIAL PERMIT - Approved ay <br />Pit/Sump Soli Character: <br />PE SC Received Amount Date Permit/ <br />Service Re uest # <br />Invoice* Permit ID* <br />4:3,0 Az; s 0 __.4.10,_Remitted q <br />CONTRACTOR 6444n*/ 14 /4 <br />CONTRACTOR ADDRESS ,e2"1/6 CIA0u <br />LICENSE 4-42 0:;C-36 OTHER <br />WATER TABLE DEPTH: 02.0 <br />PERC TEST <br />TYPE OF WORK: <br /> APN (1M:7 ty2A, PARCEL SIZE _______ <br />NUMBER ,445-50'V.r. EXPIRATION DATE IT- 3 0 iq <br />SUMPS 2 t,t <br /> <br />DISTANCE TO NEAREST <br />NUMBER <br /> <br />WELL ft FOUNDATION <br />W10114 <br />WELL / ft FOUNDATION <br />SEEPAGE PITS <br /> <br />DISTANCE TO NEAREST <br /> <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4201. <br />5/5;17