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. .z ONSITE WJ�fEWATER TREATMENT SYSTEM P 41T r SAN LOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT - 304E WEBER AVE-3"°FL�OCKTON CA 95202 - (209)468-3420 0! I^ R r NON-REFUNDABLE PERMIT CALL209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 'Lill) d w ) !CITY/ZIP l� �OA D CROSS STREET LGyy IrT)R APN 0'0 Ly /` o / OWNER NAME - { �n _ 'rc"� _ /PHONE✓SC)[/734— Y T OWNER ADDRESS �L1 �E�A 11C31�1 �/'e- - \' .n St�tl� CITY/STATEJZIP L rr ��vo CONTRACTOR T-"�'-"- _ PHONE_ CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C�12 U C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: fl GEOGRAPHICAL INFORMATION: Coordinates X Y ~ 1 ❑ PERC TEST N - SL'ILDINC PERMIT# LAND USE APPLICATION# TYPE OF WORK: ❑ NEW INSTALLATION - REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCI ' NUMBEROFLIVING UNITS:_ I NUMBEROF BEDROOMS: �1-� - .+vmeew urs'.nsnAEvir v:°'' ❑ SEPTICTANK TYPE/MFc CAPACITY ❑ CREASE TRAP TYFrJMFG CAPACITY \ _ ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATIOR� _.._._-...._._... - - U LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) O LEACH LINES ❑ LEACHING CHAMBERS #OF LINES _ LENGTH OF LINES ft DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft FILTER BED WIDTH. -2 -_ft LENGTH y1 2d R DEPTH �Ss�r R I yy DISTANCE TO NEAREST WELL S C� R FOUNDATION I fl PROPERTY LINE S R ❑ MVUNDED WIDTH ft LENGTH ,ft DEPTH ft DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE It LI IMPS WIDTH ft LENGTH R DEPTH ft _CC DISTANCE TO NEAREST WELL ft FOUNDATION_ R PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH _ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE _ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCETO NEAREST WELL ft FOUNDATION R PROPERTY LINE_--ft I HEREBY CERTIPY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQCIN COUNTY ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. - MINI UR ADVANCE pNO-TICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED �a -�..--Qot TITLE. 0UJ►�12C DATE 2-� li .1 — s� i - 1 I N I I O - i I r 1 DEPAM 1..-' RTENT_US NLY-x_ _ _ _1� Date .� ��Arca -� � Employce IDN Application Accepted Final Ins lion By �'�- �^/ Date [I SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: - IIII OMMENTS �i a�i FO e PE SC Received Amountate Permit/ Invoice# Permit IDN Code INFO B Ca Remitted Service Recluest N ONSITE WASTEWATER PERMIT 42-02-001 12/22f2003