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JOB ADDRESS <br />CROSS STREET CI G try <br />LICENSE LI _C-42 LI C-36 OTHER NUMBER 701EXPIRA1ION DATE - <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />BUILDING PERMIT # LAND USE APPLICATION # <br />NEW INSTALLATION <br />REPLACEMENT <br />TYPE OF WORK: <br />A <br /> <br />INSTALLATION WILL SERVE: RESIDENCE <br /> <br />NUMBER OF LIVING UNITS: <br /> <br />(4., SEPTIC TANK TYPE/MFG <br />GREASE TRAP TYPE/MFG <br />WELL -5.72 /4- ft DISTANCE TO NEAREST: <br />TYPE OF PUMP D PKG TX PLANT LIFT STATION SIZE SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />tk- (Oy <br />L8t. pod& <br />PAYMENT <br />RECEIVED <br />JAN 1 5 2021 <br />42-01 <br />04/18 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />OWNER NAME <br />OWNER ADDRESS <br />7 <br />CONTRACTOR A. bAAA,-(1,7 PHONE -/g4/y <br />CONTRACTOR ADDRESS /0 '9 7 CITY/STATE/ZIP S/Viiat/t/ 1SS311013V 311S REPAIR/ADDITION <br />_ OUT-OF-SERVICE SEPTIC SYSTEM <br />ENGINEER DESIGNED /ALTRNA"1E <br />DESTRUCTION (.2)/(L_ 7 -yyj <br />OTHER <br />NUMBER OF EMPLOYEES: <br />CAPACITY _/.2,...0c5> gal # OF COMPARTMENTS <br />CAPACITY gal # OF COMPARTMENTS <br />FOUNDATION ft PROPERTY LINE "--"2-• ft <br />0 COMMERCIAL <br />NUMBER OF BEDROOMS: <br />LEACH LINES r LEACHING CHAMBERS <br />DISTANCE TO NEAREST <br />FILTER BED WIDTH <br />DISTANCE TO NEAREST <br />El MOUNDED WIDTH <br />DISTANCE TO NEAREST <br />SUMPS WIDTH <br />DISTANCE TO NEAREST <br />DISPOSAL PONDS WIDTH <br />DISTANCE TO NEAREST <br />CI SEEPAGE PITS NUMBER <br />DISTANCE TO NEAREST <br /> # OF LINES LENGTH OF LINES ft <br />ft FOUNDATION ft PROPERTY LINE ft <br /> ft DEPTH ft <br /> ft FOUNDATION ft PROPERTY LINE ft <br />ft DEPTH ft <br /> ft FOUNDATION ft PROPERTY LINE ft <br />ft DEPTH ft <br /> ft FOUNDATION ft PROPERTY LINE ft <br />ft DEPTH ft <br /> ft FOUNDATION ft PROPERTY LINE ft <br /> ft DEPTH ft <br />ft FOUNDATION ft PROPERTY LINE ft <br />WELL <br />ft LENGTH <br />WELL <br />ft LENGTH <br />WELL <br />ft LENGTH <br />WELL <br />ft LENGTH <br />WELL <br />WIDTH <br />WELL <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 />MINI , a ' 48 HOUR A TICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) -7697 <br />SIGNED 7V' TITLE /=72 DATE <br /> rE JOAQUIN COUNTY <br />E1NVIRONMENTAL <br />ALTH DEPARTMENT <br />Application Accepted <br />Final Inspection By 11 <br />Character of of Soil to De!stisfs3p: <br />COMMENTS <br />PE <br />Code <br />SC <br />INFO <br />R ceived Check#/ Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Permit ID# <br />L+Z.J 0 f i 3 11 1 1/'`=' 3 c)0 1.1c)-21 So0C1).-1Wq--- <br />((—Hertr ) <br />(A. f-\ PARTMENT US <br />Date <br />Date <br />ONLY <br /> <br />Area Employee ID# <br /> <br />0 SPECIAL PERMIT -Approved by <br />itiS mppoil Ch,g4er: <br />I rse °it I 1, <br /> flrY1 <br />WATER TABLE DEPTH: <br />PERC TEST # <br />PHONE <br />CITY/STATE/ZIP