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PERC TEST # <br />TYPE OF WORK: 0 NEW INSTALLATION <br />LI REPIACENIENT <br />LICENSE AC-42 0 C-36 01HER NUMBER <br />WATER TABLE DEPTH: <br />BUILDING PERMIT # <br />it GEOGRAPHICAL INFORMATION: Coordinates X <br /> <br />LAND USE APPLICATION # <br />REPAIR/ADDITION 0 ENGINEER DESIGNED /ALTERNATIVE <br />CI DESTRUCTION <br />EXPIRATION DATE <br />INSTALLATION WILL SERVE: <br />NUMBER OF LIVING UNITS: <br />ZI RESIDENCE c&COMMERCIAL <br />NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ZO <br />OTHER <br />TYPE/MPG <br />TYPE/MPG <br />DISTANCE TO NEAREST! WELL It FOUNDATION <br />SIZE TyPE OF PUMP <br />O OF COMPARTMENTS <br />OF COMPARTMENTS <br />CAPACITY gal <br />CAPACITY gal <br /> <br />ft PROPERTY LINE <br /> <br />ft <br /> <br />GI SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br /> <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE - 3" FL - SrocicTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />/6/%9X >14,.,/tr CITY/ZIP '%v ,&6ct.,..rjr <br />JOH ADDRESS <br />CROSS STREE1 -ie2e/A..74,,e1.4) 40.4.9747 APN q 3 .7b2- PARCEL SIZE <br />OWNER NAME ii,4,ed4,4/ PHONE 9g.3. 7-17/4,0 <br />PHONE <br />CONTRACTOR ADDRESS T Y / S T A TE/ Z P <br /> <br />OWNER ADDRESS <br />CONTRACTOR <br />CI T V /ST A T E ZI P :SS3HOUV 3.11S SEPTIC TANK <br />GREASE TRAP <br />PKG TX PLANT <br />LIFT STATION <br />DISTANCE TO NEAREST <br /> <br />WiDTH <br />DISTANCE TO NEAREST <br />WIDTH <br />DISTANCE TO NEAREST <br /> <br />WIDTH <br />DISTANCE TO NEAREST <br /> <br />DISPOSAL PONDS WIDTH <br />DISTANCE TO NEAREST <br />SEEPAGE PITS NUMBER <br />DISTANCE TO NEAREST <br />LENGTH OF LINES ft <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />ft LENGTH ft DEPTH tl <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br /> tt LENGTH ft DEPTH ft <br />WELL ft 12iiiNDDrkTION ft PROPERTY LINE fi. <br />,jui ft LENGTH J (4114,1allir ft DEPTH 0 / ft <br />WELL f t ft FOUNDATION /D ft PROPERTY LINE 5--- 0 <br />ft LENGTH It DErrti ft <br />WELL ft FOUNDATION II PROPERTY LINE ft <br />WIDTH ft DEPTH ft <br />WEI.L ft FOUNDATION ft PROPERTY LINE ft <br />FILTER BED <br />MOUNDED <br />SUMPS 73 <br />LEACH LINES U LEACHING CHAMBERS # OF LINES <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br />ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />M NIJft5R HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (2091953-7697 <br />DATE 812,hts <br />Ai <br />rIF-AE::IMIE 'E.\ '17: ..") <br />SIGNED TITLE <br />no's•- AOC 1 2C (14 <br />SAN .10.0411.1N ;loutai <br />Eftvi11I0 79e1'rA1 <br />DErARTMEK-T <br />47, <br />4041-44. Z4/0, <br />$L, <br />VON" 1 IM1111111111111•11 <br />cle.st <br />-a? <br />Thrr <br />5/tc? <br />eql:0,,ea-774C111_,/ <br />DEPARTMENT U ON Y <br />Date Area Employee 11)4172, <br />te <br />Pit/Sump Soil Character: Character of Soil to Depth <br />COMMENTS <br />Application Accepted By <br />Final Inspection By <br />41.110:"--.G.0001, 0 <br />.0. <br />F <br />0 SPECIAL PERMIT -Approved by <br />Nrket <br />- • • otel 4.7 " <br />PE <br />Code <br />SC <br />INFO <br />Received --C- <br />By <br />Check101 Amount <br />Remitted Date Permit/ <br />Service Request tt Invoice S Permit ID4( Cash <br />1126 7--al 2,..e_- I P9-3-S- 45 70 7 ktivie 5 "e tv-il 0 1- .. <br />-' <br />...--,+, <br />,... <br />e=t4-......—.4.. —,c_ t'.---• ---W°- -a-r. -' C) ." -,e--...... --/->e-S-4---#(:"5., 14 ....I PV" . Wk...., <br />42-02-00 =-016"" Cr4ISPOi7eir-ASI IiSaMel9** 1212712003 <br />Orkl ,