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Pi 00 <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMF <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AvE-3`°FL-STOCK ON 468-3420 <br /> NON-REFUNDABLE PERMIT CALL 20 3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FkWMATE ISSUED <br /> L r"/- �F a-�[e 264 CITVIztP Q -I <br /> JOBADDRESS 30 Ir t <br /> CROSS STREET 20N., 'io7A- �" _ APN � - PARCELSIZE r' 1 <br /> OWNER NAME 1 d �X►1N PHONE <br /> OWNER ADDRESS CrrY/STATFJZIP <br /> CONTRACTOR 4e�/LI Ml� �• PHONE d-�'�•'f"0 <br /> CONTRACTOR ADDRESS rea CITYISTATEIZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X �lfl <br /> ❑ PERC TEST # BUILDING PERMIT - ZQ V LAND USE APPLICATION <br /> TYPE OF WORK: ❑ NEw INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> X REPLACEMENT Q DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL 151 OTHER <br /> NUMBER OF LIVING UNITS: -Q-- NUMBER OF BEDROOMS: -6-- NUMBEROF EMPLOYEES: A�- <br /> SEPTIC TANK TYPE/MM CAPACITY t koo-2J006gai NOFCOMPARTMENTS F� <br /> C2 GREASE TRAP lYPFIMFG CAPACITY gal N OF COMPARTMENTS ).T1 <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL 50 R FOUNDATION L R PROPERTY LME _ ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS # rl:TN LENGTH OF LINES ft <br /> DISTANCETONEARFSF WELL ft FOUN ATION ft PROPERTY LINE <br /> �S FILTER BED WIDTH 20 _ft LENGTH DEPTH <br /> DISTANCE TO NEAREST WELL L C'31 7 ft FOUNDATI x C7 PROPERTY LINE R <br /> ❑ MOUNDED WIDTH j-�- ft LENGTH � —#t`'` DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> Cl SUMPS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH- 1t DEPTH fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE FL <br /> ❑ SEEPAGE PITS Numork W[DTR R DEPTH ft <br /> DISTANCETO NEAREST WELL R FOUNDATION R PROPERTY LINE fl <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIN NCFS,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> ...1121 UR ADVANCE NOTICE REQUIRED FOR INSPECTFONS-PLEASE CALL(209)953-7697 <br /> SIGNED �Jtr+ _ TITLE�dA.+eL-��ilNrll.Fe�Y DATE Z� <br /> f V v <br /> I S <br /> V <br /> r <br /> Oz J C' <br /> U � i <br /> [ ml <br /> o� LLuji <br /> L <br /> N <br /> or 2L <br /> S P <br /> ti 4l <br /> llgo <br /> Application Accepted B Date Area /_[_� Employee IDq d <br /> Final Inspection By Irate '❑ SPECIAL PERMIT-Approved by I!L <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS I-OS— k N/! dG b � IIIb c°Gs � Cr���m,��rJ <br /> PESC Reeeived heck#! Amount Date Permif! Invoice# Permit IIM <br /> Code INFO Bv Remitted Service Request# <br /> ZS izz ?r1 4IS4.3 k z <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 1222!2003 <br />