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f S r�fi6AQU1N COUNTY ENVIRONMENTAL TREATMENT TMENT ESYSTEM EBER AVE - �PERMIoN CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSJ�d ep ^ CITY/ZIP <br /> CROSS STREET t� APN syi " [J " ARCEL SIZE — C <br /> OWNER NAME73 P1 tom` PHONE ...b <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTORADDRFSS d U � CITV/STATEIZIP <br /> LICENSE C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TAKE DEPTH: ft ]GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION E3REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ Ru_PLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE. ❑ COMMERCIAL ❑ OTHER_ <br /> NUMBER OF LIVING UNITS:_ NUMBER OF BEDROOMS: NUMBER o EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG �rqL� CAPACITY Q�C� gal 4 OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LJ LEACHING CHAMBERS c� /'t #OF LINES — _ LENGTH of LINES / I ft <br /> t <br /> DISTANCE TO NEAREST WELL �ft FOUNDATION R PROPERTY LINEC�� ���}� ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH V 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 R <br /> 13 sumps WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION_ ft PROPERTY UNF, ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ^ <br /> I HEREBY CERTIFYTHAT 1 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. VV11� <br /> MINI M 24 H R ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 <br /> SIGNED TITLE / DATE__ �a"cpr <br /> n <br /> r <br /> 1 � <br /> f Ir, <br /> wit, <br /> k <br /> j OA Uli C U ZWAI LEL H o 161 N <br /> +H <br /> " <br /> ,P PARTMENUSE ONLY <br /> A plication Accejtr�jpth <br /> y Date Area Employee <br /> Final Inspection BDate ���d. 11 SPECIAL PERMIT-Approved by _ <br /> Character of Soil of 3 Ft; Pit/Sump Soil Character:COMMENTS IA <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B 'Cash) Remitted Date est# Invoice# Permit ID# <br /> 241 t 111 0 36V <br /> 42.01-001 <br /> 12/2/02 ONSITE WASTEWATER PERMIT <br />