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ONSITE. WAS'1'1;WA'1,1?IZ 'I'IZF,A'I'MEN'1' SYS-1' PC!(�Ti <br /> f' <br /> SAN JOAQUIN CIIIIN'I'V EN VIRONMEN'1'AL I IF:AIA 11 DF MI:NT 314 E W1':I1ER A MO i'1.- t 1CA 95 q2 -,( 0 �r4?i 1 <br /> NON-REFUNDABLE PERMIT BALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 V FROM GATE ISSUEb <br /> 7 <br /> bN <br /> JOB ADDRESS s/v CITY/ZIP ITI <br /> -j <br /> a <br /> CROSS STREET APN ' ! O 0 P ELS SIZE01 <br /> I <br /> v <br /> ()jr <br /> X <br /> OWNER NAME iV ' 'PHOONE /y� -O <br /> OWNER ADDRESS �O- � 1 CITY/STATE/ZIP LSV v <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X /- Y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# rA-11!!)3 <br /> t/ <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDI);IOy 13ENGINEERDESIG ED/ALTERNATIVE <br /> Cl REPLACEMENT 1/,4 DESTRUCTION <br /> INS'T'ALLATION WILT.SERVE: ❑ RFSIDENCF: ❑ COMMERCIAL ❑ O•rulk <br /> NIIMIII•:R OF LIVING UNITS: NUNIBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION tt PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LlLEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE ti <br /> ❑ FILTER BED WIDTB fl LENGTH fl DEPTH Tt <br /> DISTANCE TO NEAREST WI I.I. 11 FOUNDATION ft PROPERTY LINE It <br /> ❑ MOUNDED WIDTH tt LENGTH ti DEPTH t1 <br /> DISTANCE TO NEAREST WELL fl FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE tt <br /> ❑ DISPOSAL PONDS WIDTH 11 LENGTH it DEPTH_ tt <br /> DISTANCE To NEAREST WELL 11 FOUNDATION R PROPERTY LINE Il <br /> ❑ SEEPAGE PITS WIDTH 11 L'.NGTH Il DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE fl <br /> I HEREBY CERTIFY 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 /> I KeM HOUR HAD I'1 F:REQUIRED FOR INSPF;CT•IONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE OW�`7� DATE <br /> V CLVd COVEMD M H AS►ATWO.DRIVEWAY/,ANO WA *. M~M"00 Am""FROM" <br /> FfCc— w <br /> t-oo c rei E' =. <br /> PAYMP ,r <br /> E V <br /> REC,VVEn ... <br /> OCT.Q 9 <br /> N Mll G jul ITY1 <br /> -• EPME ur <br /> DEPARTMENT SE NLV ��(� <br /> Application Accepted By Date Area V1 / Employee ID <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by / <br /> Character of Soil to Depth of 3 Ft: it/Sump Soil Character: <br /> COMMENTS _ <br /> i L., <br /> PE SC Received Chec Amount Pernli/ <br /> Code INFOI ken <br /> ash Remitted Date Service Request# Invoice# Permit ID# <br /> 07 R - l pp'3�5J <br /> 42-01-001 <br /> 12/2102 ONSITE WASTEWATER PERMIT <br />