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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMEN"FAL HEALTH DEPARTMENT 304 E WEBER AVE-3—FL-S"rOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL.(209) 53_7697 F1'7R IVSPECI IONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> t' JOB ADDRESS [ CyY` O1 17 <br /> t(J ; N <br /> 1 7 <br /> ' CROSS STREET ApN <br /> PARCEL SIZE <br /> OWNERNAME <br /> T <br /> --�'�• PHONE <br /> OWNER ADDRESS CITV)ST'wTE/llp --- �j <br /> CONTRACTOR j�zrA _ PHONE <br /> CON TRACTOR ADDRESS <br /> LICENSE ❑C-42 (3 C-36 OTIIER NUMBER EXPIRATION DATE_ <br /> f <br /> WATER TABLE DEPTH: / 11 GEOGRAPHICAL INFORMATION: Coordinates X _ y <br /> ❑ FERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> ' <br /> TYPE OF WORK: ❑ NF,WINSTALLATION REPAIR/ADDITIONC) ENGINEER DESIGNED/ALTERNATIVE <br /> C2 REPLACEMENT ❑ DESTRUCIION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER i <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYE.FBC <br /> EI'TICTANK TypE/MFC�5F/1C-�C CAPACITY ^_ gel #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MF'G• CAPACITY _ L <br /> — gel #OF COMPARTMENTS <br /> ❑ li TX PLANT DISTANCE TO NEAREST: WELL Ft FOUNDATION <br /> ----. ft PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPE OF Pup ❑ SAND OIL SEPARATOR(ENCLusim „y) <br /> LEACH LINES ❑ LEACHING CHAMBERS #of LLNE <br /> LENO)'li Of L.IN&S ft <br /> v <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE, fl <br /> ❑ FILTER BED WIDTH—_�Y R LF r DEPTH <br /> R <br /> DISTANCE'rO NEAREST Wf.[,L ft FOUNDATION li PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH R LENGTH R DEPTH <br /> III <br /> DISTANCE TO NEAREST W'E[.l. R FOUNDATION R PROPERTY UNE tt <br /> ❑ SUMPS WIDTH----—-t1 I-ENUTH R DEPTH <br /> ft <br /> DISTANCE To NEAREST WKI.t• _ft FOUNDATION _R PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH --_ti LENGTH ft DEPTH <br /> fl <br /> DISTANCE.Tq NEAREST WELL R FOUNDATION fl PROPERTY LIVE $ r <br /> ❑ SEEPAGE PITS NUMBER WIDTH fl DEPTH_ <br /> R <br /> DISTANCE TO NEAREST WELL fl FOUNDATION $ PROPERTY LINE <br /> I HEREBY CERTIFY THAT F HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY + <br /> ORDINANCES,STATE LAWS AND RULES AND RECUL ATIONS OF SAN JOAQUIN COUNTY. <br /> MINIM N 24 HOUR ADV.4 CE NOTICE REQL'IRF:D FOR INSPECTION'S-PLEASE.CALL('_09)953-7697 <br /> SIGNED�f�2'✓If! *1� TITLE DATE <br /> S <br /> O <br /> F <br /> T <br /> ..._. _ DE•P*RTMENi'U- ON,V - <br /> Application Accepted By Bt Area _ Employee IDP.! <br /> Final Inspection B _ ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to p of t: PIM mi it Character: <br /> COMMENTS l <br /> t PE SC Received Chec Amount Permit/ <br /> Code INFO 81 Cash Remitted Date Service R uest# invoice# Permit ID# <br /> Z . <br /> 42-02-001 <br /> 121'21.2D03 ONSITE WASTEWATER PERMIT <br />