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ONSITE WAT. ATER TREATMENT SYS PERNIIT SAN JOAQUIN COUNTY ENVIRONMENTAL,HEALTH DEP:._..MENT 304 EL�,SL °FL-ST CA 95202 -.(Z09)468- . NON-REFUNDABLE PERMIT CA/LL(209 953-7697 FOR INSPECTIONS .EEx A i) ISSU JOB ADDRESS oz- 6/0�/] pµ//w1�� ST �^"T"'��- CITY/ZIP -3 MV'� •"'��dd CROSS STREET 'T L/V APN _f_Z� O za �6 PARCEL SIZE IIS .� : OWNER NAME 7 `� /�/ -� PHONE OWNER ADDRESS S Z0 -2— CITY/STATE/ZIP CONTRACTOR A j: /v/�" �� `� + �/<��A PHONE CONTRACTOR ADDRESS zqoe CITYISTATE/ZIP x; LICENSE 13 C-42 ❑C-36 OTHER Z NUMBER / EXPIRATION DATE_' O WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X AY ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED 1ALTERNATIVE ig - ❑ REPLACEMENT 'DESTRUCTION tL h�� INSTALLATION WILL SERVE: EJ RESIDENCE L3COMMERC AL . ❑ OTHER 64- NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES::': ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF.COMPARTMENTS ❑ PKG TX PLANT DiSTANCETO NEAREST: WELL R FOUNDATION ft PROPERTYLINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ' ❑ LEACH LINES - ❑. LEACHING CHAMBERS #OF LINES LENGTH.Ox.LINES.'` DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE'' "` ft. ❑ FILTER BED WIDTHR LENGTH ft DEPTH $"i j ` }t DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE'S' R AS ❑ SUMPS WIDTH ft LENGTH ft DEPTH x ft DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINEft y ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LME ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN �j 1M 24 HOUR ANCE NOTICE REQUIRED FOR INSPECTIWS--�PLEASE CALL(209)953-7697" S SIGNED l/(/� TITLE �f V F 4 y. iL A ;• : J G _. N ti .Y DEPARTMENT US^ ON Y Application Accepted Date S e)S Area 4Emplpyee 1D# Final Inspection B Date ! 12SPECIAL PERMIT��,ApprQved by Character of Sail to De h of 3 Ft: Pit/Sump Soli Character: COMMENTS 01_r 7-70,J o � S�-ccL7u.P.,�S • � �y �-L. . ��"�S°�'on�f " �i�c r'7` PE SC Received Amount Permit/ Dat InYoice# ��r' 'fPcrmit 1D# F Code INFO AYA Cash Remitted Service Request# - /� fl F �2-2[ O'1S OD•Ota �7/�C.l`�T � z A. " 42.02-001 �l/�� SOLS • .�I �.^ '�ON�S,ITEWASTEWA7ERPERM[T '�>+ 12/22/2003