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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN'JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE .3" FL - STOCICTON CA 95282 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7691 FOR INSPECTIONS �1EXPIRES I YEAR FROM DATE ISSUED <br />JOB ADDRESS 3t2 tb.... Wets Mo+re;hg C� CITY17IPT/IC,� ( 204. <br />CROs STAF,FT ]p�+t /B�SAP/N �' /00 <br />"' p f •,PARCEL SIZE <br />OWNER NAME _ ✓Y; W!1/(Ct1'-oi fr�rl S `Yio�'i �C� ✓lC% Gx�, / �� Jam; / <br />PHO.Nl: <br />OWNERADDRE53 Z 6 l/"lfy MD r�� Gt, �'� CITYISTATPJZIP 5• 1. <br />,_.4 !-LA <br />CONTRACTOR {i ult !z I� sem, oG I A,T F s �f: �' ( -Jl / Z - ., _ _ . _ _ <br />f CONTRACTOR ADDRF,SS <br />�- C ITYlITAT}1%IP L // (' LF UL'�/frS-1 <br />T� E <br />LICENSE LIC -42 3C-36 OTHER UMBER <br />-- EXPIRATION DATE <br />WATER TABLE DEPl'tl; _ fl GEOGRAPHICALINPORMATION: Coordinates X <br />Y <br />F-5 P❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />7YPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITIO' <br />❑ ENGINEER DESIGNED /ALTERNATfVF. <br />❑ REPLACEMENT DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMF.RCIAl. J R � jp TH.�_�. <br />NUMBRR OF 1.1 VINC U MTS: NUMBEROFBEDROOAtS: )•.-„ 66A Y11!!1 !! �Ma . �,.i�`�. i�-�— <br />❑ <br />❑ <br />❑ <br />❑ <br />SEPTIC TANK <br />GREASE <br />GREASE TRAP <br />PKC TXPE. ANT <br />LtFTSTATION <br />TYPE-R$fG_____ <br />TYPElMEG <br />D1STANCET0NEARRST; WELL <br />_-- <br />SIZE TYPE OF PIMP <br />CAPACITY PF=ft {pay! ire V8 t�r{'F1RSP.%Ri1�F�CGS' `j <br />CAPACITY "'�illClVLi nNtt ('iU V11fC('tJtti` <br />R IONWCTya"kajHRIW BGL <br />�❑ffiPfebtlitl�El4� i - <br />SAND — n <br />OIL SEPARATOR (ENCLOSED SYS F-%4) <br />❑ <br />LEACH LINES <br />❑ LEACHING CHAMBERS <br />_4 OP LINES LENGTH or LINES <br />DISTANCE TO NEAREST WELLR <br />FOUNDATION ft PROPERTY LINE <br />__.-.. <br />El <br />FILTER BED <br />WIDTH R LENGTH <br />...... <br />DISTANCE TO NEAREST WELL i <br />....R DEPTH <br />ft FOUNDATION t! <br />ft <br />❑ <br />MOUNDED <br />WIDTH....:.._. R LENGTH <br />PROPERTY LINE <br />DISTANCE TO NEAREST WELL <br />ft DEPTH <br />R FOUNDATION R <br />❑ <br />SUMPS <br />WIDTHft <br />R LENGTH <br />PROPERTY LINE <br />DISTANCE TO NEAREST WELL _ <br />_ ft DFmi R <br />R FOUNDATION R <br />❑ <br />DISPOSAL PONDS <br />WIDTH R <br />PROPERTY LINE <br />-R <br />_ LENG'ill <br />R DEPTEI R <br />Dom NCE TO NEA REST WFf.I. <br />ft R <br />FOUZATION <br />SEEPAGE PITS <br />NualeER WIDTH <br />_ PROPERTY LNE ft <br />- <br />DISTANCET'ONEARM WELL <br />DFPTH R <br />ft POUSOATION <br />ft PROPERTY LINE ft <br />1 HEREBI' CER'lTF'Y THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br />ORDINANCES,. STATE LAWS AND RULES <br />AND REGUL.ATIONSOP SAN JOAQUIN COUNTY. <br />3'�• % <br />lN(MY4_� HOUR ADVANCE NOTICE REQUIRED <br />FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED (L/.� <br />,p <br />'I112E e�){v+rc DATE _l <br />'l. <br />i <br />0 <br />'-� DEPARTMENT qSE ONLV , <br />Application Accept 3 <br />.__ Date Area -_ Employ= IDA <br />Final Inspection Date�� ❑ SPECIAL PF.RMI7'-Appmvcdby <br />Character or Soil to th of 3 F[: PiUSumP SD(I Character: <br />COMMENTS __wE E -ca �Ui.1. AVy _..PrLro 2 fRx i rS_ o �I Fc t �jc�TiG.Cll� <br />�Dfi�crGr.-f� <br />'z <br />PR <br />5%�!� tX.� <br />SC Received Chec Amount PermiU <br />Code INFO Cash Remitted Date Invoice Permit ED# <br />Service R uest# ' <br />�Zz( ops <br />fav, 00 IZcZ0-14 X345 * j <br />2iz2noo3 3d C!��Ffb 1�•�E <br />IT W.ASFEWATER PERMt,-w7 � <br />