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ONSITE WASTE Vt,'y R TREATMENT SYSTE. ,► RMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEA(A If DEPARTMENT 304E WEBER AVE -3X°1'C-S OCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)9$3-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> Jon ADDRESS �.� %i L y <br /> CITY/ZIP a <br /> m <br /> (1NI)tiN S'1'RY.):1A 5ILE $s <br /> / T '7 sOs <br /> OWNER NAME r.�r �� /�7( PIIONE =AN(IEL 7 —� d y <br /> y <br /> OWNERADDRESS CI'I'V/S'FATt:/LIP �'�r�(� �/ /��t <br /> COMI'NAII /'OR G✓�///11J[iPHONE �(J// ) � S S- S9,4 � Y� <br /> CON'I'RA(TOR ADDRESNS C�-s r97vlU Ci'il'/S'1'A'1't7Zlp �/S ^7 <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE W <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERCTEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: JerNEw INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: 'SIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: � NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: q <br /> SEPTIC TANK CTYPOMFG Gwcw ar APACITY 1 �_ gal #OFCOMPARTMENTS {T <br /> ❑ CREASETRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS rr�� <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ' R FOUNDATION it PROPERTY LINE R ^, <br /> �❑✓ LIFT STATION SIZE TvPE OF Pump ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) f <br /> qt LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES <br /> ✓\ Dis rANC'E'1'O NEAR XI • WELL / � II FOUNDATION Il PROPERTY LINE J �� To <br /> ❑ FILTER BED WIDTH II LENcrH B DEPTH R <br /> DISTANCE TO NEAREST WELL fl FOUNDATION H PROPERTY LINE fl <br /> ❑ MOUNDED WIDTH R LENGTH Il DEPTH R <br /> DISTANCE TO NEAREST WELL H FOUNDATION H PROPERTY LINE R R� <br /> ❑ SUMPS WIDTH R LENGTH H DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE fl <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPTH R <br /> DISTANCETO NEAREST WELL R FOUNDATION tl PRO7TY LLIIN�E- R <br /> .. SEEPAGE PITS WIDTH 42- LENGTH R DEPTH 1 7 7 T R <br /> DISFANCETo NNEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICN AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> r ,TATE LAWSA RULESA EGULATIONS OF SAN JOAQUIN COUNTY. <br /> INIMU 1 H R A.DVA/N[j/N[jT E REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 C/ <br /> SIGNKIV rTITLE (✓' DA J <br /> 1 i <br /> i <br /> I i I <br /> i <br /> i <br /> i <br /> 1 i � <br /> 1 i i <br /> 1 i i <br /> 1 I i <br /> 1 i i <br /> 1 I i <br /> 1 <br /> Iy 1 .l <br /> I <br /> I <br /> 1 <br /> I <br /> L------------------------ ----------- ------ <br /> -T <br /> ---- -- J <br /> oe.�.. <br /> n �� <br /> ------------------- -------- <br /> i <br /> DEPARTMENT UNE O LY <br /> Application Accepted Br 4EqzDate U; Area — [� Employee ID -53 ,g <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Characler or Son to Depl ora F1: . ����i�.-. P / ump Soil Character. r 2y <br /> COMMENTS 5f E' <br /> y &W6 <br /> PE SC Reteived Che Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B as Remitted Service Request# <br /> 0 618000-:3 el-I <br /> 12/2102 �h�cr�►7-<v£, ��f,.i � c �F-- /x'xiGYJ�'I� W j <br /> .+�ac'ATS <br />