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'. ONSITE WASTEWATER TREAT? -NT SYSTEM PERMIT <br /> ` SAN JOAQUIIP`*IONTY ENVIRONMENTAL HEALTH DEPARTMENT %W004E WEBER AVE 3"FL-S1oUx TON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209 953-7697 FOR INSPECTIONS EXPIRES 1.VEAR FROM DATE ISSUED <br /> JOBADDRE55 Ar, V A ..•, - ^ CITU/ZIP :—Ik-\< 1', <br /> ` <br /> CROSS;STREET <br /> STReEr C.. ",i n \ wPN j%] L' '✓ -`'y" V �• PARCEL SIZE ~ <br /> OWNERNAME .a ..� I"3e r <br /> OWNER ADORGSS L 'F.T k ~ ��^ H' r� CITY/$TATF121P <br /> L CONTRACroIF N V PHONE, i -, v 1 <br /> CO UTORADDRESS CITY/STAMDP <br /> LICENSE ❑C42 ❑G36 OTHER NUMBER EEMRATION DATE <br /> l_ WATERTABLEDEPTH: ft GEOGRAPHICALINPORMATION: Co9rtllxRtn X Y <br /> PERCTEST # BUILDING PERMIT III LAND USE APPLICATION SO <br /> TYPE OF WORK: ❑ NEWINSTALWTION ❑ REPAIR/AODHION ❑ ENCUNEERDxMGNeo/ALTauWnVE <br /> L ❑ REPLACEMENT ❑ DESTtUCITON <br /> INSTALLATION WILLSERVE: L3 RESIDENCE ❑ COMMERCIAL L3 OTHER <br /> NUMBEROP LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> L ❑ SEPTIC TANK TYPE/MFG CAPACITY 8B1 R OF COMPARTMENTS <br /> ❑ GREASE TRAP TVPE/MFO CAPACITY 8e1 A OF COMPARTMENTS <br /> ❑ PRG TX PLANT DISTAN"TONEAREST: WELL R FOUNDATION ft PROPERTY LNE ft <br /> ❑ LIFT STATION SIE¢ TYPE OF Pump O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> I <br /> L ❑ LEACH LINES ❑ LEACHING CHAMBERS R OF LINES LENGTH OF LINES R <br /> DIETANCET(NEAREST WELL ft FOUNDATION ft PROPERTY LIFE ft <br /> ❑ FILTER BED WIDTN ft LENGTH ft DEPTH OF <br /> DISTANCETONEAREST WELL ft FOUNDATION R PROPERTYLNE ft <br /> ❑ MOUNDED WIDrx ft LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMPS Wmrx ft LENGTH It DEPTH ft <br /> DISTANGRTONLUEST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH R <br /> • DISFANCETONEARES2 WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS Numeea WIDTH ft DEPTH R <br /> j DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> 1r` I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DOME IN ACCORDANCE WITH RAN JOAQUM COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE RF.QVI RED FOR INSPECTIONS-PLEASE CALL(209)9534697 <br /> LSIGNED TITLE a +�— DATE <br /> i <br /> L <br /> N O p IN ',OJKY <br /> I <br /> as <br /> -1p <br /> L <br /> 1 <br /> J V <br /> r_ <br /> - /' DEPARTMENT USE ONLV -- <br /> Application Accepted By - { '"-`-"-- Data Z' /`-�' A. Employee Im <br /> Pinel lnrpeedon By Date ❑ SPECIAL PERMIT-Appmvcd by <br /> Chander of Soil to Depth of 3 Fe PiVSump Soil Character: <br /> COMMENTS <br /> �. PE SC R.I,m Ch.w AmountPermitl <br /> Code INFO -_C h Remitted Dam Service ueetA InvakeB PerMe11N1 <br /> 12-02-001 ONSITE WASTEWATER PERMIT <br /> I2YJYJ003 <br />