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ONSITE WA� EWATER TREATMENT SY ` ' PE <br /> a� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTDEPARTMENT <br /> H' RM S,T g� c <br /> NON-REFUNDABLE PERMIT 304E WEBER AVE -3"°FL-STO o _ <br /> CALL 209 953-7697 FOR INSPECTIONS EXPIRES A 420 <br /> JoBADDRESS � I d TE I SUED <br /> T CITY/ZipSj <br /> CROSS STREET r arl I\ e �,1 ��. -3 <br /> 1. APN PARCEL SIZE Y <br /> OWNER NAME I f+^ � e Q G <br /> PHONE Lo <br /> ."' /�2�S'(�/f►,n t <br /> DINNER ADDRESS <br /> S I a V re <br /> -/� <br /> � F CITY/STATE/ZIP <br /> P i <br /> CONTRACTOR `�- q <br /> PHONE/ 2 G I-,r�3 8 0j i <br /> CONTRACTOR ADDRESS � <br /> CITYISTATE/ZIP <br /> LICENSE ❑U42 ❑C-36 OTHER <br /> NUMBER U <br /> WATER TABLE DEPTH: EXPIRATION DATEft GEOGRAPHICAL INFORMATION: Coordinates X U <br /> ❑I PERC TEST # <br /> $UI sDING PERMIT# y <br /> t3 3 S LAND USE APPLICATION# <br /> TYPE OF WORK: New INSTALLATION <br /> ❑ AND <br /> ❑ ENGINEER DESIGNED(ALTERNATIVE <br /> ❑ REPLACEMENT <br /> ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE; ❑ RESIDENCE <br /> COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br /> I, MBEROFEMPLOYEES. �D � <br /> SEPTIC TANK TYPE/MFG 1112- 1 <br /> CAPACITY Fb gal #OF COM PARTMENTS <br /> ❑ GREASE TRAP TYPFJMFG <br /> CAPACITY gal #OF COMPARTMENTS <br /> ❑ 4 PKC TX PLANT DISTANCE TO NEAREST: WELL <br /> r ft FOUNDATION ft PROPERTY LINE ft . <br /> ❑ °LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES x LEACHING CHAMBERS #OFLINEs <br /> , LENGTH OF LINES 0 O I ft I <br /> DISTANCE TO NEA REST WELL CO) ft FOUNDATION I l <br /> ❑ (FILTER BED WIDTH ft PROPERTY U fY <br /> F ft LENGTH ft DEPTH ft I <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE I� <br /> ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH <br /> ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE f} <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION <br /> R PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> 1 HEREBY CERTI THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 VANCE NOTICE REQUIRED FOR INSPECTIONS w PLEASE CALL(209)953-7697 <br /> SIGNED TITLE <br /> DATE <br /> 1 <br /> 1 <br /> +✓ <br /> 5 <br /> MEN <br /> ,,I E i a <br /> E:( i <br /> 00 <br /> L <br /> Al. N G N <br /> PIT <br /> _- - - — <br /> rf <br /> DEPARTMENT SE C! <br /> Appliciatioit Accepted By Date Area Employee ID# o l <br /> Final Ilnspection By Date 1 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to De th of 3 Ft: tlSump Soil Character: <br /> f <br /> COMMENTS <br /> PE `` SC Received Check#/ Amount Permit/ <br /> Code` INFO $ ash Remitted Date Service Request# Invoice# Permit ID# <br /> `ri' Vu s AjCS u 7 -� <br /> 42-02200 <br /> ]2!221/2003 ONSITE.WASTEWATER PERMIT <br /> ` F <br />