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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAOLIN CCUNTY ENV IFCC NMENTAL HEALTH DEPAATh1ENT 1868 Iw HA7,ELTON AVENUE•S70CXTCN CA 45205-(209)4683420 <br /> NoN-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECT70NS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jo8AocRESS_ 4040 W- K-W&A6tj /Lt> - C-rrYIz,P L-ob <br /> CROSSSTREP Aj CCG r APN �� -ZSo -Z I PARCEL SIZE �' 1rc' y <br /> o,,.c.NA.E Ltb � ��yC IJ f PNONE C91Cc� <br /> OWNER ADDRESS s q5"f❑ GVl�fr1� [- o,e C i jr CTY/S ATEMP SFtcr�+rnc11�-o �1 i ZC1__- <br /> CONTRACTOR LIVE OT"� CJ't 0C"VI40^JyKCY'F-A-Z PRONE 3[apt-037 <br /> o <br /> CnrmaacrDR ADDRESS N1 L)fCK ST c"rTATEmp L OD lr C-A '172-4c.') <br /> ^ <br /> LICENSE DOC-42 LSIOC-36 OTHER ` NUMBER 2,t S� EXPIRAMON DATE �- `3�--L--L <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: COOrdinateS X Y <br /> ]S PERC TEST k BUILDING PERMIT# LAND USE APPLICATioN# <br /> TYPE OF WORK: z NEW INSTALLA-nON REPAIRIADDRION C ENGINEER DESIGNED/ALTERNAT{VE <br /> REPLACEMCNIT _ OV7-OF-SERVLCESFP71CSYSTEM E DESTRuC1TON <br /> INSTALk.ATk0N WILL SERVE: D RESIDENCE _ COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: Nu A:B ER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gel #OF COMPARTMENTS <br /> ❑ GFIFIISE TRAP TYPJMFG CAPACrTY gal #0F COMPARTMEYS <br /> DISTANCE TO NEAREST: WELL ft FouHDAnoN ft PROPERTY LINE ft <br /> © UFT STATION SIZE TYPE OF PUMP O PxG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS *CFLINES LENGTH OF LINES It <br /> DISTANCE TO NEAR ESr WELL_ ft FOUNDAT10N ft PRCPERTYLINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYUNE ft <br /> ❑ MOUNDED WIDTH fI LENGTH It DEPTH ft <br /> DISTANCE TD NEAREST WELL ft POUNDATON ft PROPERTYLINE ft <br /> ❑ SUMPS WIDTH ft L6YGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It POUNDAnON ft PROPERTY URE ft <br /> • DISPOSAL PONDS WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE ft <br /> • SEEPAGE PITS NUMBER W=H ft DEPTh ft <br /> DISTANCE TO NEAREST ')YELL R FOUNDATION R PROPERTY LINE ft <br /> I HERESY CERTIFY TN AT HAVE PRVAS ED THIS APPUC ATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAO ULN COUNTY ORDINANCES, <br /> STA7E LAWS AND RULES AND REGULATIONS OF SAN JCAOUIN COLI NTY. <br /> N1N1UUMM 487hiOLIR AL)VAVCF NOTICE RE UIRED FOR INSPECTIONS-PLEASE CALL E209)953-7697 <br /> SIGNED i' TITLE �I�.] N'L CY lz, DATE <br /> I I II <br /> I <br /> ;P..Sip F <br /> I IV D <br /> X000 <br /> oEp�N�ry� <br /> f _ DEPA ATMEN U E ONLY L! 41 Employee Application Accepted By ` 08te QL? Area <br /> Final Inspection By Date SPECIAL PERMIT•Approved by <br /> Character of Sokl to Depth of 3 Pr: PitiSump Sail Character: <br /> COMMENTS <br /> PE SC Received Che Amount Permit) <br /> Cade INFO 8 as Remitted Date Service R uest# Invoice V Permit IDV <br /> �LIaaa sZ13 Asa w S <br /> I <br /> 62.07 ONSITE WASTEWATER TRTSANT SYSTEM PERMIT <br /> 4O W18 <br />