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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> Ran SAN JOAQUIN COUNry ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE-3®FL-STOCRTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953 W FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRFSS 1 Q IL CM/ZRCIS4L?,r�T7 <br /> Rao CROSS STREET pPN r�i�-/>JU SIO PARCEL SITEI p <br /> OWNER NAME 1 -""ySf V- PHONE <br /> OWNERADDRESS ` CITY/STATVZIP <br /> Ran, COWFAcTOR O *N PHONE <br /> CONTRACTOR ADDRESS a.i: CIYYISTATE/ZIP <br /> LLICENSE 3C4 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> kr WATERTABLEDEPFH: R GEOGRAPHICAL I NFORMADON: CDordloaler X V <br /> PERC TEST p 'I/ BUILDING PERMIT# LAND USE APPLICATION III <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIVADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLAcemEw ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: 13IDENCE RPS ❑ COMMERCIAL 13 OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBEROFEMPLOVEES: <br /> ❑ SEPTIC TANK TYPFJMFG CAPACITY SRI #OF COMPARTMENTS <br /> {`r ❑ GREASE TRAP TYPFJMFG CAPACITY Sal #OFCOMPARTMENTS <br /> ❑ PKC TX PLANT DIWANCETONEARESI': WELL It FIXMDATMN R PROPERTY LME <br /> ,1 <br /> L ❑ LIFT STATION SITE TYPEOFPUMP ❑ SAND OIL SEPARATOR(ENCLQBEDSvYENO <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF II LENGTHOFLINER ft <br /> DISTANCETONEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> L ❑ FILTER BED WIDTH R LENGTH ft DEPTH R <br /> DISTANCETO NEANFST ELL A FOUNDATION R PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH R <br /> DISTANCETONEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH R LENGTH It DEPTH ft <br /> LDISTANCE TO NFARM WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIoGn ft LENGTH R DEPTH ft I <br /> DISANCETONEARESr WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NomaeR WIDTH R DEPTH ft <br /> BDISTANCETO NGNEST WELL ft FOUNDATION ft PROPERTY LINE R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TRE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY: <br /> MI%IMUM E4 HOUR AD\'ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(201913-7697 <br /> LSIGNED =4 TIME _ _ I,—-� DATE — 1"�', <br /> L <br /> ) T <br /> L f y IN <br /> l M <br /> 1` <br /> \a I I <br /> PARTMENT US ONL <br /> LAppilca[lon Aaeptetl Bye l /�['l.l. ��L� Dale -f �� Ara Employce IDp - f"✓•� �' <br /> Final Inspection By Dale ❑ SPECIAL PERMITApprovedby <br /> Chaneter of Soli to Depth of 3 FO PH/Sump SOII Character: <br /> COMMENTS <br /> I <br /> L PE SC RB9¢IvW Citdh l4-' Annuut Mle PermiU Invoice# Permit LOS <br /> Code <br /> In B Caab ReMHad ServlceR ueal# <br /> It. 42-@4plL ONSITE WASTEWATER PERMIT <br /> V2V2003 <br />