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ONSITE WA..'_'7EWATER TREATMENT SY(_ EM PERM! <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH"DEPARTMENT 304 E WEBEhAVE -3"°FL-STOCKY N A 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7197 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS O MORDY A4—,--WI7-rCITY/ZIP <br /> Zi NDEN 195-2-34 g- ! <br /> w r . ^ /7 /� / / 2-Z� <br /> / 0 a <br /> CROSS STREET F�A F- 9OA-b APN �3—V3(/ —(e 6 PARCEL SIZE a <br /> OWNER NAME AILTL+ R_( 154AII A60A P/HON+,E92,SS` �Z'�� 0226 y i <br /> OWNER ADDRESSyL N ��I•(�I TT �w•' _ _ CITY/STATE/ZIP LIN 0 /E'•y p <br /> 1;-3 4, <br /> O <br /> CONTRACTOR Civ L /V PHONE 6 <br /> I <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP 71A R L d GSL <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> I <br /> WA ER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# - <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION I7 ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />�' ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY, gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE R <br /> 0 LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> E <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> I <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH 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 ft <br /> ❑ SUMPS WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> E <br /> I HEREBY CE 1FY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> DINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MIN OUR ADVANCE.NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED DATE ��'1-3 0� <br /> t I <br /> L <br /> l ' 0 <br /> E � <br /> PAYMEIN <br /> E <br /> f <br /> F <br /> E, <br /> E W <br /> E <br /> �. S NN Joj CL N <br /> DI <br /> PRTIAENT <br /> I <br /> Ig <br /> DEPARTMENT USE ONLY <br /> ��Application Accepted By / Date' - Area Employee IDA <br /> Final Inspection By Dale Y 8 ❑ SPECIAL PERMIT-Approved by _ <br /> Character of Soil to pth of 3 t: P Sump Soil Character: <br /> COMMENTS <br /> 4 _ _ <br /> P PE `'SC Received hec Amount Permit/ <br /> Code `yINFO <br /> {1}B Cash Remitted 11 Date Service Re uest#x Invoice# Permit ID# <br /> a <br /> E,. <br /> 42-02.001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />