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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT _?;'n SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3" FL-STOCK-rON CA 95202- (209)469-3420 I NON-REFUNDABLE PERMIT CALL(2091953-7697 FOR INSPECTION:S /� �r EXPIRES 1 YEAR FROM PATE ISSUED 20F ADDRESS l/��pp �{ ww'1 CITYIZIP/}_�f •. �. a CROSS STAFF-7' VY T 1(!y VI APN a �jL`� PARCEL SIZE - v OWNER NAME Tw 4 F PHU.'E OWNER ADDRESS r OY —I C. /L.t;...L• • �r �J [TlSTATFIIP_ CYZ �y f C(INTRALTOR M�{!��/Y�1� ♦aY� (I',I'Coo 9",�fA CONTRACTOR ADDRESS I f l 1 ��/�'�yy �✓I�Q��j1 MAY CITT'%'ISvTA'r�E/ZIP & d L!^ �{/� '-Y LICENSE. O C-42 ❑C-36 OCHER �•1'{ klAl tiUMH[A EYPIRA7'[ON DATE. WATER TABLE DEPTH: It CROCRAPIIICAL INVORNA NON: Coordinates X_ Y C PERC TEST(S) NCMBF.R LAND USE APPLICATION H — /t{ TYPE OF WORK: ❑ NEW INSTALLATION 0 RE AIA/ADDrnun' ❑ ENGINEER DESIGNED lALTE TIVC ❑ REPLACEMENT O bESTRDCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ C04MERCIAL [] OTHLR NUMBER OF LIVING UNITS: NUMBER OF OLDRDOMS: NUMBER OF EMPL01'EF,S; ❑ SEPTIC TANK 'RPEIMFG CAPACITY _ gal NOFCOMPARTMENTS ❑ CREASE TRAP TYPEIMFG CAPACITY _ dal HOF COMPARTMENTS ❑ PKC TX PLANT DISTANCE TO NEAREST: WELI- Fl FMJXDArION _ it PROPERTY LINT: Il ❑ LIFT STATION SIZE TYPE OF PUMe ❑ SAND OkL SEPARATOR(ENCI.OSEDST.Mm) ❑ LEACH LINES ❑ LEACHINC CHAMBERS H Or LINES LENGTHOFLINus f3 LA,;DISTANCE TO NEAREST WELL fl rOUNDAT10N Il PROPERTY LINE LIFILTER BED WIDTH ft -Jnr R LENGTH R DEPTH DISTANCE TO NEAREST WELL R FOUNDATION Ft PROPERTY LINEh, ❑ MOUNDED WIDTH ft It LENGTH A DEYrtI DISTANCE TO:NEAREST WELL I1 L R FC1C1NpATION li PROPERTY LINE f f ❑ SUMPS W7D71IR It ft f[ DEPTH R DISTANCE TO NEAR ME WELL H FOUNDATIOS R PRUPERTYl.ISE Q DISPOSAL PONDS WIDTH R R LENGTH R DEPTH r DISTANCE TO NEAREST WELL6 h fi FOUNDATION It❑ PROPERTY LINE n �(SEEPAGE PITS WIDTH ti LENGTH Rf fl DrPrH DISTANCE TO NEAREST WELLII FOUNDRY"ION R It PROPERTY LING % )HEREBY 'ER'r Y THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE 1N ACCORDANCE WITH SAN Jr) N GUI;N"rY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN CODNTY. tMI"I'MM 24 HOUR ADVANCE NOTICE REQUIRED FOR I N5PECTION;S-PI-r:A.4F:C'ALI,f-'09)913-7647 SIGNED TITLE �t� y`}"f� ea DATE Ir .01 3 S1: I '.O t V ,k � UI ------------- ----------- A 1 i L' DEPARTMENT :E ON(.Y Application Accepted By /C Daft !C' - -� G L' � Area Employee IDR zI cce" Fln.l Inspection By _ Dorc ❑ $PECIALPERMIT-gppruvedhy Character of SOII to Depth of 3 Ft: COMMENTS PluSufnPSOU Character: �K Z 3 t{� / sr, o PE SC Received Cheeks/_/; Amount COdc Inep gDate PrrmiU -Cfifi Remitted Service R nest# Invoice 9 Permit IDD 4? ; S /�n U U kit 5't'. 42AIa103 - - - - / 12r2r'91 - C - ONSTrE WASTEWATER F, i