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f <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3',,FL-STOCRTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 204 953-7697 FOR INSPECTIONS WXPIRES I YEAR FROM DATE ISSUED <br /> JOBADDRESS 17, <br /> CITYJZIPAIX <br /> CkOSS STREET ✓�4 T-}(V � <br /> APN b - 6U „Z, PARCEL ZI:� <br /> r tl <br /> OWNER NAME a <br /> t^ �G'(�1;j LhGPHONE � <br /> O WNER ADDRE55 CITY/S'rATdZIP <br /> CONTRACTOR 011 <br /> 1T� <br /> CONTRACTOR ADPRE55 „-,-- r�O' t£ C1TYISI'ATE-1- Q� <br /> LICENSE ❑C-42 Q C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABL[DEPT7[:_ fl GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ FERC TESTBUILDING PERMIT# LAND USE APPLICATION-------------- <br /> t! <br />! TV PE OF WOR K: ❑ NEWINSTALLATION ❑ REPAIRIADDITEOH <br /> ❑ EVC[NEER DESIGNED IALTERNATFVF. <br /> :3REPLACEM F,NT C3 DESTRUCTION <br /> INSTALLATION WILLSERVE: ❑ RESIDENCE C] COMMERCIAL ❑ OrHER <br /> NuMRER OF LI VINO UNITS: NUMBER OF BEDROOMS: ND'4[DCR OF EMPLOYEES: <br /> A SEPTIC TANK TYPElMPG_ CAPACITY _ gal NOFCOMPARTMENTS_ <br /> ❑ GREASE TRAP TYPUMFG_ CAPACITY gal 9OFCOMPARTMENTS <br /> CI PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION A PROPERTY LINE <br /> 'fl <br /> ❑ LIFT STATION SIZE - TYPE OP PUMP ❑ SAND OIL SEPARATOR{ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS 9 O LINES <br /> —� LENGTFI GF LINES <br /> R <br /> DISTANCE TO NEAREST WELL R EOt1NDAT[ON_ It PROPERTY LINE <br /> (3 FILTER RED WIDTHn <br /> A LENGTH ,R DE" fi <br /> DISTANCE TO New REST WELLft FOUNDATION R PROPERTY LINE <br /> (3 MOUNDED wtprx �. n <br /> R LF,NGTH tt B£Pfli n <br /> DISTANCETO NEAREST WELL n FOUNDATION fl PROPERTY LINE <br /> ❑ SUMPS WmTHft <br /> R LENGTH fl DEPTH <br /> DISTANCE TO NEAREST WELL _ft FOUNDATICN' (I ft <br /> PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTH ft <br /> ' R LENGTH_ f5 DEPTH ft <br /> DIRTANCETO NEAREST WEIJ- _J1 FOUNDATION R PRpPERTY LINE <br /> Q SEEPAGE PITS NUMBER WIDTR —R <br /> it DrFIH n <br /> DIRANCL70N¢wkeST WELL fl FOUNDATION ft PROPERTY LINE <br /> R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WELL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES A ND RECU LATIONS OF SAN JOAQUIN COU NTY, <br /> MINIMUM i HQUR ADVANCE NOTICE RF,QVIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE; DATE <br /> -------------- <br /> r <br /> 1 <br /> M <br /> r <br /> DSP RTMENT FAr" <br /> APpllention Accept DateEmployee IDkFinal Inlpecfiae Hy DateCIAL PERMIT. <br /> Charncler of S'ril to Depth o(3 t: Approved by <br /> PiUSump Soll Character: <br /> COMMENTS <br /> PG 5C Received ChecldU Amount Permitl <br /> Code [NFO 8 as emitted Date Ic --t Invoice# Permit ID# <br /> 12-02-0O1 <br /> 17/7271003 ONSITE WASTEWATER PERMTr <br />