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JOB ADDRESS /"." "-- <br />CROSS STREET /4e3C/01404 47:. 62 4 71 <br />OWNER NAME <br />OWNER ADDRESS CITY/STATE/ZIP <br />CONTRACTOR rFizi(—A.v—z1/5 "044y-1i/ft_ fci - PHONE e-Z3 <br />CONTRACTOR ADDRESS <br /> CITY/STATE/ZIP <br />LICENSE A.17.6-42 1110C-36 OTHER <br /> <br />NUMBER C'()' EXPIRATION DATE <br /> <br />CITY/ZIP <br />2 10 9 <br />PHONE <br />0 - APN PARCEL SIZE <br />BUILDING PERMIT # LAND USE APPLICATION # <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - S-rock-roN CA 95205 -(209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209)953-7697 FOR INSPECTIONS E PIRES 1 YEAR FROM DATE ISSUED <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X <br />PERC TEST # <br />INSTALLATION WILL SERVE: E RESIDENCE <br />NUMBER OF LIVING UNITS: <br />WELL <br />1:1 LIFT STATION SIZE TYPE OF PUMP <br />I. I DESTRUCTION <br />ENGINEER DESIGNELftlectivelveE <br />EDIVT' <br />El <br />NUMBER OF EMPLOYEEA: <br />CAPACITY gal # OF COMISIAIrliK, <br />CAPACITY <br />TS 22 <br />gal # OF Com "'AQUitv rs„„ <br />Cry 06,--ttl-fArrAu Pill' ft FOUNDATION ft PROPERTY LINE '-' ^kr(rlidElo. ft <br /> 0 PKG TX PLANT 0 SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />Li SEPTIC TANK TYPE/MFG <br />GREASE TRAP TYPE/MFG <br />DISTANCE TO NEAREST: <br />E COMMERCIAL E OTHER <br />NUMBER OF BEDROOMS: <br />TYPE OF WORK: NEW INSTALLATION <br />REPLACEMENT <br />REPAIR/ADDITION <br />OUT-OF-SERVICE SEPTIC SYSTEM <br /> <br />LEACH LINES [1 LEACHING CHAMBERS <br />DISTANCE TO NEAREST WELL 57, i71- ft <br />ID FILTER BED WIDTH ft LENGTH <br />DISTANCE TO NEAREST ft FOUNDATION WELL <br />MOUNDED WIDTH ft LENGTH <br />LENGTH OF LINEs 0> <br /> <br />ft <br />ft PROPERTY LINE .5' Li- ft <br />ft DEPTH ft <br />ft PROPERTY LINE ft <br />ft DEPTH ft <br /># OF LINES <br />• FOUNDATION /t/ -7^ <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />SUMPS WIDTH <br /> ft LENGTH ft <br /> DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />DISPOSAL PONDS WIDTH ft LENGTH ft <br /> DEPTH ft <br />FOUNDATION ft PROPERTY LINE ft <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />SEEPAGE PITS NUMBER WIDTH 3 / <br />DISTANCE TO NEAREST WELL /00 71.. ft FOUNDATION /71 ft PROPERTY LINE ft <br />I 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 />MI 48 HOU jVA <br />SIGNE <br />E NOTICE_REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE DATE :SS311aCIV 311S 4.9 <br /> are% <br />Application Accepted 13 <br />Final Inspection By <br />Character of Soil to De <br />COMMENTS <br />11c190‘,:y rik:tolej S 0-, <br />PARTMENT U <br />kieNtarragir-21 <br />of 3 Ft. <br />Date <br />Date <br />Area tf /9E1 Employeiel# <br />0 SPECIAL PERMIT - Approved by <br />Pit/Sump Soil Character: <br />E •NLY <br />PE <br />Code <br />SC SC <br />INFO <br />Received <br />By <br />Check# Amount <br />Remitted Date Permit/ <br />Service Request # <br />Invoice # Permit ID# <br />s <br />i t5- dia 2aszt--C- 12 e& 10 n sg 00•6493 4210 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />42-01 <br />4/14/18