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ONSITE WA -EWATER TREATMENT SYSTEM P)�T <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL /ARTMENT 304 E WEBER AVE-3""FL KTON CA 95202-(209)468-3420 <br /> NON-REFUNDCA�LjL(20 )/}9_53-7697 F R INSPECTIONS EXPIRE$1 YEAR FROND DATE ISSUED <br /> JOB ADDRESS - "• OD •' ril'C .CITY/ZIP •, I 'y <br /> ',j I/I'�`� fF, �f'y`. ,�Y-f �i In <br /> CROSS STREET ff,, r APN(A5-0;W / �' i PARCEL SIZE 3.j5 �'1✓ o <br /> OWNER NAME 7vc No 1 d inin i <br /> OWNER ADDRESS I�l �(�,P/—y//�jjj�fU ty� �s�'�f 1 f _ CITY/STATE/ZIP ti/`-" / CA q�-yJZI, <br /> CONTRACTOR NEI I A 1'�tD U1 ? ! S-ZI CS PHONE Q69 �" _DID <br /> CONTRACTOR ADDRESS 0Z -'^'V 1 U5 ( I `'Y CITY/STATE/ZIP Ltd, I rA t 52 1" ' <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER ExPIRATION DATE .� <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OFEMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS -1-421 <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE fl <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES Il <br /> DISTANCETO NEAREST WELL ft FOUNDATION - ft .PROPERTY LINE fl <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION- ft PROPERTY LINE fl . <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETONEAREST WELL 'ft FOUNDATION R PROPERTY LINE ft - <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft.FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH fl <br /> DISTANCE TO NEAREST WELL _ R .FOUNDATION It PROPERTY LINE ft ' <br /> 1 HEREBY CERT AT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> _STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> 24 HOUR ADVANCE NOTICE REQUIRED FOR INS P I ; <br /> SIGNED TITLE DATE (Q„P �S fALL(209)953-76g7 / C O�� . <br /> m( v O <br /> 9-105.5' <br /> 171.4' °� <br /> N i9�9. <br /> CN <br /> 467 411.36' 59' <br /> N <br /> 0 <br /> r E 4�y O PA <br /> 380 g <br /> 72.1' <br /> JPARTMENT USE �iNLY//� (/ <br /> Application Accepted By L•'d—/ Date b /r! /Area Employee ID# 0I 1 / // <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PIUSump Soil Character: <br /> COMMENTS ; <br /> PE SC Received Che Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By, Cash Remitted Service Request# <br /> 42-01.001 <br /> 12R/02 - ONSITE WASTEWATER PERMIT <br />