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a <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRON _NTAI. IIE:A LTH DEPARTMENT' 304 E WEBER AVE -3- FL- S'I'OCK'1'ON CA 95202 - (209) 468-3420 <br />NON-REFUNDA E PE CALL (209) 953-7697 FOR INSPECTIOSS EXPIRES I YEAR FROM DATE ISSUED <br />JOHADDNESS <br />❑ LEACIIING CHAMBERS <br /># or LINES LENGI'll OF LINES <br />Il <br />Permit/ <br />DISTANCE I'D NEAREST WELL <br />73 <br />Il <br />CROSS S'I'HEF.T <br />�' [� <br />ppN ­6-2-0k'7'y�s J� PARCEL SIZE �I <br />o <br />�t <br />OWNER NAME <br />r►1 <br />ft <br />OWNER ADDRESS <br />WIDTH D LENGTH <br />ft DEPTH <br />III <br />y) <br />CONTRACTOR D - <br />^ /�� <br />1 . P,4- i <br />r /� �� k, /,/C1ITY/STATE/LIP <br />` S/2C�11�1 \1! IK PHONEJ L/I//�� <br />� <br />CONTRACTOR ADDRESS` 'V <br />Ki <br />�-��JI� 1�o <br />tlV �5F )1�/ hi�Y`� CITY/STATE/ZIP �C:+��ILJI'/Iv! /�`W' 5 <br />R DEPTH <br />LICENSE C-42 <br />❑ C-36 0'1"HER <br />-�� - UMBERtons EXPIRATION DA'T'E t O ✓ <br />R FOUNDATION 11 PROPERTY LINE <br />WATER TABLE. DEPTH: <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />D GEOGRAPHICAL INFORMATION: Coordinates X <br />, 1 <br />❑ PERC TEST (S) <br />NUMBER <br />LAND USE APPLICAI"ION # <br />R <br />TYPE OF WORK: <br />❑ NEW I INSTALLATION <br />❑ REPAIR/ADDITJON _I ENGINEERDk'SI(:NED/ALTERNA'T'IVE <br />R <br />❑ REPLACEMENT �f[i DESTRUCTION : - <br />R FOUNDATION H PROPERTY LINE <br />INSTALLATION WILL <br />SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING <br />UNITS: <br />NUMBER 0I7 BEDROOMS: NUMBER OF EMPI.OYF.E:S: <br />❑ SEPTICTANK <br />TYPE:/MFG <br />V U CAPACI"FY gal #OF COMPARI'MEN"1'S <br />(� <br />❑ CREASE TRAP <br />TYPE/MFG <br />CAPACITY gal # OF COM PARTMENTS <br />❑ PKG TX PLANT <br />DIST'ANCEI'O NEAREST: WELL R FOUNDATION Il PROPERTY LINE Il <br />❑ LIFT STATION <br />SIZE <br />TYPE OF PUMP ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />❑ LEACIIING CHAMBERS <br /># or LINES LENGI'll OF LINES <br />Il <br />Permit/ <br />DISTANCE I'D NEAREST WELL <br />tl FOUNDATION R PROPERTY LINE <br />Il <br />❑ FILTER BED <br />WIDTH 11 LENGTH <br />B DEPTH <br />_ Il <br />� <br />DISTANCE To NEAREST WELL <br />R FOUNDATION R PROPERTY LINE <br />ft <br />❑ MOUNDED <br />WIDTH D LENGTH <br />ft DEPTH <br />III <br />DISTANCE TO NEAREST WELL <br />R FOUNDATION ft PROPERTY LINE <br />0 <br />❑ SUMPS <br />WIDTH ft LENGTH <br />R DEPTH <br />ft <br />DISTANCF.TO NEAREST WELL <br />R FOUNDATION 11 PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH <br />It <br />DISTANCE To NEAREST WELL <br />fl FOUNDATION ft PROPERTY LINE <br />R <br />❑ SEEPAGE PITS <br />WIDTH R LENGTH <br />R DEPTH <br />R <br />DISTANCE TO NEAREST WELL <br />R FOUNDATION H PROPERTY LINE <br />R <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />SL'AT'E LAWS AND RULES AND REGULATIONS QF SAN JOAQUIN COUNTY. <br />M IML 41H�Ol�JR A \' 1 F: )T'ICE REQUIRED <br />� <br />POR SPk '7'lHINS- 1 EASE CALL (209) 953-7647 <br />SIGNE <br />(/ <br />}�� <br />1 ^ W \ TITL DATE <br />PE <br />SC <br />Received Check#/ <br />Amount <br />Permit/ <br />Code <br />INFO <br />By s I <br />Date <br />Remitted <br />Otvolce # Permit IU# <br />Service Request # <br />/ <br />� <br />42-01-001 <br />12/2/02 ONSITE WASTEWATER PERMIT <br />�9 <br />