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a <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />VI 0 •-•E' 1/41 e.r.T PHONE 4/W OWNER NAME <br />CITY/STATE/ZIP ark v) ea 9oj- C--' <br />PHONE <br />CITY/STATE/ZIP <br />OWNER ADDRESS -Po v"k- ox 1-4 0 <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />f <br />NUMBER EXPIRATION DATE LICENSE C-42 0 .C-36 OTHER <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X <br />BUILDING PERMIT # LAND USE APPLICATION # <br />REPAIR/ADDITION ENGINEER DESIGNED /Ali.TERN,ATIVE <br />OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION I <br />TYPE OF WORK: NEW INSTALLATION <br />REPLACEMENT <br />INSTALLATION WILL SERVE: r RESIDENCE I COMMERCIAL OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - &roc KION CA 95205- (209)468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED :41111(1V :CLIS E PERC TEST IS <br />JOB ADDRESS 01.5-0 c.f. -"RdSa CITY( <br />CROSS STREET ri‘e- 11 0-- 1- 11-/ APN 0 070501 <br />PARCEL SIZE <br />LEACH LINES LEACHING CHAMBERS ti OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />FILTER BED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />MOUNDED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />SUMPS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />NIIMUM 48 HOUR !ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 <br />SIGNED TITLE Ir-3,-"•=1:E2C7„, DATE - CLI <br />OA), teo- <br />iti4 <br />ot4ti474,, <br />4i? <br />r--"" )71 <br />a <br />SEPTIC TANK TYPE/MEG CAPACITY gal # OF COMPARTMENTS <br />GREASE TRAP TYPE/MPG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br />LIFT STATION SIZE TYPE OF PUMP <br /> <br />PKG TX PLANT 0 SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />Application Accepted By 0.--L-7-7 L <br />Final Inspection By Date = SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS +0 be, demo fisbEci <br />DEPARTMENT USE ONLY <br />Date ///XidU Area r-i/ 61 61 Employee 10# DA <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By, <br />CheckS/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request it Invoice ft Permit IDS <br />1-I I 3 75- 6."4- . de,64-1- -is" 22-?1 () ZOOZ,7 i <br />42-01 <br />41418 1175277_51 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT