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11-.>D ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />IRASAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARPMENT 30lE WEBER AVE -Vo FL -SE KTON CA 95202-(20A)468-3420 <br />NON-REFUNDABLE PERMIT <br />❑ <br />CALL (2091953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />JO/ADDRESS <br />MOF LINES <br />LENGTH OF LMES <br />J1,44 4I/tn <br />41 CTrrJED <br />Dare <br />Remittd <br />J <br />y2 --L <br />'2 <br />Ll <br />/33 <br />CR(58 STp[EE <br />Aq <br />APN P1AA44 RCEL RgIEAS _ <br />OWNER NAME <br />OMER ADDRESS <br />loeo <br />R FOUNDATION <br />PHONE <br />CTEIIVIATVLIP ../ <br />CrnTTMCTOR <br />J MA <br />FILTERBED <br />a1Mh <br />PHONE �709 jw*L'S,EE <br />R <br />DEPDI <br />R <br />O <br />LoD� <br />CONTRACTOR ADDRESS <br />DIATANCETp NEAR[ST <br />WELL <br />CRYBTATFJZIP <br />O <br />'f <br />LICENSE ❑Ci2 <br />LI C-36 <br />OTHER <br />MOUNDED <br />NUM/ 0.ulL <br />E%HMTION� <br />WATER TABLE DEPTH: R GEOGMPHICAL INFORMATION: CDPTNNRkf X V <br />r. PERC—TEST (S) NUMBER I LAND USE APPLWATIONN <br />TYPE OF WORK: ❑ NEW INETALLATON ❑ REPAIR/AVITON ❑ ENGINEER DESIGNED/ALTERNATIVE <br />❑ REPLACEMENT ❑ EHATRuCTION <br />INSTALLATJON WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />❑ SEPTICTANK TYPFJMFG_ <br />❑ GREASETIIAP TVPFJMFG <br />` ❑ PKGTXPLANT DISTANCEIONEARERT: WELL_ <br />❑ LiPTSTATION SIZE TYPE OPPUMP <br />CAPACHT gal H OF COMPARTMENTS _ <br />CAPACNY gal NOFCOMPARTMENTS <br />R FOUNDATION R PROPERTY LINE <br />❑ SAND OIL SEPARATOR (ENCLOSED SVRTFM) <br />1 <br />❑ <br />LEACH LINES <br />❑ LEACHINCCHAMBER5 <br />MOF LINES <br />LENGTH OF LMES <br />ft <br />L <br />Dare <br />Remittd <br />I..I.# PermD IDM <br />Senice nmlM <br />y2 --L <br />'2 <br />5-21 <br />BTS <br />DISITANCETONGREBf <br />WELL <br />R FOUNDATION <br />R PRWERTY LINE <br />R <br />❑ <br />FILTERBED <br />WIDTH <br />ft LENGTH <br />R <br />DEPDI <br />R <br />DIATANCETp NEAR[ST <br />WELL <br />R FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED <br />WIDTH <br />R LEN.TN <br />ft <br />DEPT" <br />ft <br />`✓ILII <br />DIRANCETONGRM <br />WELL _R <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />SUMPR <br />WIDTH <br />It LENDTH <br />R <br />DEPT" <br />fl <br />DISTANCETONGREST <br />WELL <br />ft FOU'll <br />R PROPERTY LINE <br />fl <br />❑ <br />DISPOSAL PONDS WiDIR <br />R LENGTH — <br />ft <br />DEPTH <br />fl <br />DISTANCETONZAREST <br />WELL <br />ft FWNDAT!ON <br />R PROPERTY LINE <br />ft <br />❑ <br />SEEPAGE PITS <br />WIDTH <br />R LENGTH <br />tl <br />DEPTH <br />A <br />DIBTANCETONEAREST <br />WELL <br />ft FOUNOATION <br />ft PROPERTY LINE <br />R <br />I REREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK .1 LL BE DONE IN ACCORDANCE WITH SAN JOAQU IN COUNTY ORDINANCE& <br />STATE LAWS AND RULES AND REGULATIONS OF RAN JOAQUIN COUNTY. <br />�NI MUM 24 HOUR ADVANCE NOTICE REQUIRED <br />FOR INSPECTIONS -PLT. SE CALL (209)953-707 <br />SIGNED Lff <br />Y7N <br />TITLE~� L <br />! S DATE <br />3 Ft: <br />6<' Aro Employm IDM S ! <br />y ❑ SPECIAL PERMIT - Approvd by <br />Pit/Sump Soil Chamkr: <br />PESC <br />NEON 0 <br />MEMBER <br />MEMBER <br />Reetlrd hee <br />■■■B■■ <br />■■■■ER <br />MENNEN <br />Pvmid <br />MEMBER <br />MEMBER <br />MEMBER <br />MEMBER <br />■■■■ER <br />MEMBER <br />In10 <br />MEMBER <br />MEMBER <br />�ME0 <br />Dare <br />Remittd <br />I..I.# PermD IDM <br />Senice nmlM <br />y2 --L <br />'2 <br />5-21 <br />BTS <br />3 Ft: <br />6<' Aro Employm IDM S ! <br />y ❑ SPECIAL PERMIT - Approvd by <br />Pit/Sump Soil Chamkr: <br />PESC <br />Reetlrd hee <br />Amount <br />Pvmid <br />Collo <br />In10 <br />B uA <br />Dare <br />Remittd <br />I..I.# PermD IDM <br />Senice nmlM <br />y2 --L <br />'2 <br />5-21 <br />D <br />4241 p1 <br />Umuln ONSITE WASTEWATER PERMIT <br />L' <br />v <br />91 <br />C.1 <br />