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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE.3°'FL-STOCICION CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS Jj• CfrY/LIP / C �/ 2 to CROSS STREET �� C-y�rJ CJ �• ,/ 'e / A P N L`13-' LSC'`2- PARCEL SIIZZE/•!J 4c. - 9 OWNER NAME �`r��jC. l�('��✓l C^' i7` `,p PRO N-E� / �I.'• 7L.+1'L OWNERADDRESS ` 336✓ ' A=lr4��'"!� CITY/STATE/ZIP S ?4- � CONTRACTOR �J!/ �' PHONE L CONTRACTORADDHESS nCITY19 ATE/ZIP LICENSE ❑C-42 ❑C-36 OTHER L NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates SL Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: ❑ NEW INSTALLATION ❑ RF.PAIR/ADDrr1ON ❑ ENGINEER DESIGNED[ALTERNATIVE ❑ REPLACEMENT ❑ DESTRUCTION INSTALLATION WILL SERVE: O RESIDENCE ❑ COMMERCIAL O OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ PKG TX PLANT DISTANCETO NEAREST: WELL it FOUNDATION fl PROPERTY LINE ft ❑ LIFT STATION SITE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES R DISTANCETO NEAREST WELL R FOUNDATION R PROPERTY LINE R ❑ FILTER BED Wlonl ft LENGTH fl DEPTH ft 1 DISTANCF.TO NEAREST WELL ft FOUNDATION fl PROPERTYLINE it U'/ ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft —1, DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LUNE ft U ❑ SUMPS WIDTH ft LENGTH R DEPTH ft DISTANCE TO NEARS WELL ft FOU\OATION R PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH R `, DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft lux ❑ SEEPAGE PITS NUMBER wtDTH ft DEPTH it DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft 1 D I HEREBY CERTIFY THAT 1 HAVE.PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY CC ORDINANCES,STATE LAWS AND RULES AND REG UI.ATIONS OF SAN JOAQUIN COUNTY. C 1 AD 'E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(789)953-7697 SIGNED 1 /T TITLE C..riz_ � DATE f 3 s 3 1 Lo� V rb�f Ver i— s L- - -1 As -I � J( -i �I l I 1n DEPARTMENT�USE,ONLY Application Accepted By /�a Date- /y,/2-,L• U q Aloe Employee ID# Y Final Ingpectiou By Date 17 SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: PiUSump Soil Character: COMMENTS CJ�F-u�u.tiya S�.I►z� .4e�,� f f l.r a`f �cc! r�,! _ 44 -1'w ,.rL tt 146.t.L3 Ic�i'lLi4d:I�E'i!�Lf%f� re.�c S�r -/i+.�k L��.n.c�rs�l-� �verL4��rt � .�F11) c�c-�J l-ecrrL�•r�/d PE SC Received Check#I Amount Permit! Code INFO B Cash Remitted Date Service R.,..,l# Invoice# Permit ID#