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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP <br /> ,NT 304E WEBER AVE-3-FL-STOCI� /7A 95202 -(209)468-3420 <br /> aa. NON-REFUNDABL�Et-PERMIIT C'�II�IL((20.9.)953-7697 FOR INSPECTIONS ' EXPIRES I <br /> #IRES -9EAR FROM DATE ISSUED <br /> JOBADDRESS ) � y5 fldnll �1 60 l�/'�':1�'� CfFY/ZIP L..t..[ i) �Z,��^ to <br /> �s � i ) <br /> T <br /> I - <br /> 7. <br /> CROSS STREET /�li.'r'1 S j.�-�{ APN 19 <br /> _PARCEL SIZE Y <br /> G}- }r� O <br /> OWNER NAME 1'rj1'� - T(-�L�1'1[�� -Pete 1 Lf <br /> ,P.HONE /'3 /'tel rmiy, <br /> OWNER ADDRESS ..) � ��j UY_ft TL r n �jf R(Cad CITY/STATEIZIP f,J�)/(_�A f i— '- <br /> CONTRACTOR i -) � t f 1�1 ) ) �•_ PHONE __7�/ti j '`I L(l I <br /> tlaa CONTRACTOR ADDRESS } y� �O (:- �� I CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICALINFORMATION: Coordinates X y <br /> _ PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# j�Af•f•i-r4P -� > <br /> TYPE OF WORK: ❑ NEW INSTALLATION 13REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE if <br /> ❑ REPLACEMENT ❑ DESTRUCTION - <br /> P <br /> NSTALLATIONWILLSERVE: El RESIDENCE L3 COMMERCIAL ❑ OTHER <br /> ti NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> C1 GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH Of LINES ft <br /> 1w DLttANCETONEAREST WELL ft FOUNDATION R PROPERTY LME ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETONEARFST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH R DEPTH ft <br /> _ DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LME R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> a� <br /> ❑ SEEPAGE PITS NUMBER WIIrfH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL - ft FOUNDATION R PROPERTY LME ft <br /> y-. <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULwA�1D AN.REG ii LATiONS OF SAN JOAQUIN COUNTY. <br /> MINIMYM HOUR ADVANCE NOTICE REQUIRED FOR INSPECT NS-PLEASE CALL(209)953-7697 <br /> SIGNED ' E�i7[�A�1. A /�--- TITLE yG�")��lr/ / DATE 7- <br /> i <br /> ti <br /> f <br /> AN J Q I C U <br /> CINVI(/ DEPARTMENTSEO/NLY HEALTH DEPARTMENT �{ <br /> w Application Accepted By ._ !t3 ---- Date _71Zr/ GVArca r,Z /Y Employee ID# 01'(9 <br /> Final Inspection By Date 13 SPECIAL PER—MIT-Approved by /r <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received (Ghee F Amount Permit/ <br /> Code INFO B ash r Remitted Date Service Reguest# Invoice# Permit ID# <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/222003 <br />