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G <br /> ONSITE WASTEWATER7� 'ATMENT SYSTEM PERMIT 5 <br /> SAN JOAQUIN COUNTY ENVIRONNUENFAI.HEALTH DEPARTMENT vJ304E WEBER AVE-P-FL-STOCRTON CA 95202 - Iv��f11-7120 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRFSS L- AH.4FiCDVEzIP z['MNPa <br /> CRO;SSTRRIT JUf'1�� "O/J�� APN PARCEL SIZE p <br /> OWNER NAME: C 7 C / ,H r PHONE: 7,06; <br /> OWNERA,:I CIT11STA'r!/ZIP <br /> ('ONrRAI"I'lIMPIIIINE <br /> CONTRACTOR ADORERS CITY/STATFJZIP <br /> LICENSE ❑C42 ❑CJh OUILS NUMBER EXPIRATION DATE <br /> WATER TARLE DEPTH: It GE(M.RAPHICALINFORMATION: CIMPTIOEtef X Y <br /> ❑ PERCTEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NF.W INSTALLATION U REPAIR/ADDITIO�N� ❑�vENNGINEEMDESIGNED/ALTERNATIVE <br /> LI ]REPLACEMENT r OE.YTRUCTION <br /> IN.STALLATIONWILLSERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER / <br /> NIIMBE0.pF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPVMFG CAPACITY EAI #OF COMPARTMENTS <br /> ❑ CREASE TRAP TYPE./MFG CAPACITY Eel #OFCOMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCETONT.AREST: WELL. A FOUNDATION 0 PROPERTY LINE it <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH of LINES ft <br /> DISrANCETONEAREBT WELL it FOUNDATION fl PROPERTY LINE fl <br /> ❑ FILTER BED WIDTH ft LENGTH D DEPTH fl <br /> DISTANCE TO NEAREST WELL R FOUNDATION it PROPERTY LINE A <br /> ❑ MOUNDED W'"'I 0 LF.NGTO H DEPTH R <br /> DISTAN(S.TONEAREST WELL ft FOUNDATION 0 PROPERTY LINE It <br /> ❑ SUMPS WIDTH 0 LENIHII fl DFPTII it <br /> DISTANIVO,NI:AMEsr WI1. R fININOAIRIN II PNOPIISTY Lon, fl <br /> ❑ DISPOSAL FONDS Wmru A LENGTH H DEPTH fl <br /> DISrANCETONEAREST WELL 0 FOUNDATION fl PROPERTY LINE fl <br /> ❑ SEEPAGE PITS NUSON, WIDTH N DEPTH ft <br /> DISTANCETONEARERT WELL R FOUNDATION 0 PROPERTY LWE D <br /> 1 OENERV VERTIFY'I IlAl I HA V v PREPARED J HIS APPLH A'TION AND I FIF WORK WILL HE DONE:IN AC(ORDANCF.WITH SAN JOAQUIN(DUSTY <br /> / OMOINANI'ES.SUAr,:LAWS AND PLAYS AND HECUTA.IONS OFSAN JOAQUIN COUNTY. <br /> MINIMUM IJ HOUR ADVANCE NOTICE REQUIRED FOR INSPF LIONS-PLEASE:CALL(209)95]_7697 /I - �/ <br /> SIGN a TITLE DATE 9'.2'G"{ <br /> L <br /> MI <br /> . 2 <br /> 0o t <br /> v T <br /> LE 0— <br /> go <br /> DEPARTMENT TEONLY <br /> APDHenlion Accept By Delle A. Employee IM SJIGSW ecp <br /> Neel lnspeclit By .GQ Dole? ❑ SPECIAL PERMIT-Approved by <br /> Cher¢cerol Pth fJ FI: P' Sump Sail Chen ter: <br /> COMMENTS <br /> AI <br /> PE SC Recelved bed# Amount Dae PermlH Invoice "Ink DDM <br /> Cnde N. 8 Re nitHd I Service Request It �- <br /> u107 -1.3010 7 1 SS 9 0 00 2 _ <br /> d$.IGAMII ONS) .WASu WATERPI'R 11' <br />