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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT�F 0-3o Z-S <br /> SAN JOAQUIN COUNTYEN'V IRO'IME]TAL HEACI'll DEPARTMENT .104 E WEBER AVE.-3"FL-ST'OCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-797 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CRY/ZIP Gd _ <br /> CAOM S,REFI' I N APN PARCEL SIZE Y = D <br /> /7RBP- 03G -15+5 <br /> OWNERNAMF. 'e(�� 7 Q.LI�g ��U�/ PHONE <br /> OWNERADDRESS CITVISfATIJZIP <br /> CONTRACTOR �,/V -(N��Z�f��i/ PHONE �lf (�7�fJ�r.(7 <br /> •/ r <br /> CONTRACTOR A DDRESST r•` ` / CITY1STwTE1ZIP V <br /> [J7 <br /> LICENSE (2<,'42 ❑C-36 OTIIER NUMBER �f'� +�Z 1 EXPIRATION DATE / V <br /> WATERTABLE DEPTH:_ (C? r 'V fl GEOGRAPHICAL.INFORMATION: Coordinates X Y_ <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# � <br /> TYPE OF WORK: FEW INSTALLATION ❑ REPAIRJADDITION ❑ ENGINEER Di.SIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION (^ <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL OTHER U✓ <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG��`T _P�iY __ CAPACITY `��D _ gel k OFCOMPARTMENTS 1 <br /> ❑ GREASE TRAP TYpr/MFG _ CAPACITY gal #OFCOMPARTMENTS t <br /> ❑ PKC TX PLANT DISTANCE TO NEARE,Cr: WELL ./`-�"� / _ ft FOUNDATION � ' _ R PROPERTY LINEC=206 ' R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 1 LEACH LINES ❑ LEACHINGCHAMBERS 0 O LINES c�P—_ LENGTHOFLi%Es .•.___ft <br /> I DISTANCE TO NEARE91" WE!A—&/O' R FOUNDATION yL_ R PROPERTY LINE �..,5 ' ft Q <br /> ❑ FILTER BED WIDTH_ ft LENGTH 11 DEPTH ft Q^ <br /> DISTANCE TO NEARESI" WELL_ ft FOUNDATION— }t PROPERTY LINE R <br /> ❑ MOUNDED WIDTH _ _ It LENGTH ft DEPTH O <br /> DISTANCE TO NEAREST WELL ft FOUNDATION _ ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH It LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL n FOUNDATION_ ft PROPERTY LINE__ R <br /> ❑ DISPOSAL PONDS WIDTII ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL IZ FOUNDAT'1AN ft PROPERLY LINE <br /> SEEPAGE PITS WIDTH �rPft LENGTH R <br /> .� � It DEPTH -"� ` <br /> / DISTANCE TO NEAREST WELL 55--0� ft FOUNDATION 4l � 11 PROPERTY LINE1�"` H <br /> I HEREBY CERTIPY THAT I HAVF.PREPARED THIS APPLICATION AND THE WORK.WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE.1. AND RULES AND REGU1AT30NS OF SAN JOAQUIN COUNTY. <br /> Ml"I M ADVA ICE REQUIRED FOR INSPE TIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> i <br /> 7111 7. <br /> I i r <br /> 5 <br /> 14 p0 <br /> 8 L Hf.L(I SE C <br /> DEPARTMENT USE O ' <br /> Application ACeeptt�• F. <br /> Dalc_q� Area mploymID#_ �. <br /> Final Inspection I <br /> Date 9 ' ❑ SPECIAJ FERMIT-Approved by <br /> Character of So"tr,Depth Ir( Ft: _--__- Pit/Sump Soil Character: <br /> COMMENTS _ ��r� ./ /���c,��C .a!� -C���a,• 7" s.,�i ��jIQ -� Q <br /> PE SC Received hee Amount Permit <br /> Code INFO ale Invoice# PermltlDk <br /> Cash Remitted Service Request# <br /> Z.I 117 - 3 310 003542.3 <br /> 42-01-001 <br /> 12J2,02 ONSITE WASTEWATER PERMIT <br />