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,("? ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE - 3YO FL - ST'OCKTTON CA 95202 - (209) 468-3420 <br />NON-REFUNDAU& pERMIT CALL 09) 953-7697 17OR INSPECTIONS EXPIRES I YEAR FROM DATR ISC1- <br />JOB ADDRESS V CITY/ZIP <br />Q -_--- <br />CROSSSTREET - PAZ. ^ APN L✓I iJ 102LnCA — <br />PweceL SIZE <br />�t 471-C� "7 <br />OWNER NAME P/+E- PHONE J� <br />OWNER ADDRESS /.(�7 DSt fTA rT�� ` 1 ` CITY/STATE/71P� -53C4- <br />CONTRACTOR �• A - t�'i 7 L-14 ) CV ,'k � f. K- i`� i _ A kl- <br />-- ' +L VCVGRAPHICAL INFORMATION: Coordinates X V <br />❑ PERC TESSTT # # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK --C3 NEW INSTALLATION <br />❑ REPLACEMENT <br />INSTALLATION WILL SERVE: RESIDENCE <br />NUMBER OF LIVING UNITS; <br />/ <br />SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />❑ PKG TX PLANT DI.STANCETO NEAREST. WELL ft FOun <br />❑ LIFT STATION SIzE TYPE OF PUMP <br />NCMBER <br />❑ COMMERCIAL <br />DESTRUCTION <br />OTHER <br />"DER OF EMPLOYEES: <br />PI #OFCOMPARTMENTS <br />ft PROPERTY LINE R <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />❑ <br />13 <br />❑ <br />❑ <br />❑ <br />LEACH LINES ❑ LEACHING CHAMBERS <br />DISTANCE TO NEAREST WELL <br />FILTER BED WIDTH ft LENGTH <br />DISTANCE TO NEAREST WE",ft <br />MOUNDED WIDTH ft LENGTH <br />DISTANCE TO NEAREST WELL <br />SUMPS WIDTH ft LENGTH <br />DISTANCE TO NEAREST WELL <br />DISPOSAL PONDS WIDTH ft LENGTH <br />DISTANCE TO NEAREST WELL <br />SEEPAGE PITS NUMBER WIDTH <br />DISTANCE To NEAREST WELL <br /># OF LINES <br />LENGTH OF LINES <br />ft PROPERTY LINE <br />DEPTH <br />_ (i PROPERTY LME <br />DEPTH <br />R PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />R PROPERTY LINE <br />R <br />_ 1 <br />•� <br />.� <br />Cft (fi <br />it FOUNDATION <br />ft <br />It <br />ft <br />}t <br />It <br />R <br />ft <br />II <br />R <br />jI <br />ft <br />FOUNDATION <br />ft <br />R FOUNDATION <br />ft <br />ft FOUNDATION <br />R <br />ft FOUNDATION <br />ft <br />R FOUNDATION <br />1 HEREBY CERTIFY THAT 1 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 />SIGNED �l <br />MINI liM i1R�C *1 1" RF.QIJIRED FOR IV L(Q,VS- PL <br />11i ' <br />'CITI. <br />.L f'_D91953.76N7 <br />DATE <br />J <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Dept f3 Ft: <br />DEPARTMENT U. ONLY' <br />Date_ t+7 Area -. Employee ID* s�C <br />Date_ ❑ SPECIAL PERMIT -Approved by ! <br />PIU p. S0.7' racier: <br />12222003 ON,SITEWASTEWATER PERMIT <br />