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r{ ONSITE WASTEWAT R TREATMENT SYSTEM PERM <br /> G�y <br /> [ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER.AVE'3-FL-SSTOC1j NJV68-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS :,EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/Zip <br /> APN `j(_/' ,"1 H— PARCEL SIZE Z � <br /> CROSS STREET `''�� / O <br /> OWNERNAME �"g' '�f2�1CPS �i+ C�--�/✓f�+ .� PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHO»E Zti�l-�OZ7 <br /> I� CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ` LICENSE C-42 ❑C-36 OTHER NUMBER EXPIMTIDN DATE <br /> I WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> r O PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# - <br /> TYPE OF WORK: NEW INSTALLATION LIREPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> FINSTALL.ATII!N;!�SR,'E-�KRESIDENCF � ❑ COMM�ERsCIAL O'I'xERNUBER / NUMBEROFBEDROOMS:� NUMBER OF EMPLOYEES: �\ <br /> OL.SEPTIC TANK TYPE/MFG 5zec&z CAPACITY OU gal #OFCOMPARTMENTSe <br /> El GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> �� 7 SS , ft <br /> El /7tJ PKG TX PLANT DISTANCE TO NEAREST: WELL ' R FOUNDATION R PROPERTY LINE <br /> ❑ LIFT STATION SIZE TYPE OF PUMP- ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES _ LENGTH OF LINES fR40 ft <br /> _ DISTANCETONFAREST WELL I7S ft FOUNDATION25 _R PROPERTY LINE /0' R <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST ' WELL R' FOUNDATION ft PROPERTY LINE R ^ <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS wmTm R LENGTH ft .pTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER----44L—WIDTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ION FOUNDATION S ft PROPERTY LINE /�� ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH'SAN JO;AQU'N COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY.. <br /> MINI /MJ24 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED <br /> TITLE �1.OJ/7�//�iy� DATE <br /> .t I <br /> E <br /> r <br /> E <br /> DEPARTMENT S N '�/'� <br /> s,�„ --'j Date t'i - Q Arca EmployeelD# <br /> !' Application Accepte y _ C <br /> • _�9 � ❑ SPECIAL PERMIT-Approved by <br /> Pinil lDspectlon 6 Date <br /> - ' Character of Soil to Depth of 3 PiUSump Soil Character: <br /> COMMENTS �O <br /> •:rPE SC Received C / AmountPermit/ <br /> Code— •.,INFO B ash Remitted Date Service Re uest# <br /> f 6 0 3 i� • <br /> !� <br /> 42-02-001 � <br /> 12/22/2003 <br />