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/ <br /> 1� = '�rONSI E WASTEWATER TREATMENT SYSTEM PER fG�4eee �� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE.3"'FL <br /> NON-REFUNDABLE PERMIT CALL,(209)953-7697 FOR INSPECTIO%S STOCI yETON CA 95202-(209)468_;020 <br /> AA EX IRES 1 YEAR- M DATE ISSUED <br /> SOB ADDRESS .(L.- �� -CITY/2t1• � � v, <br /> J�7 <br /> C0.OSS STREET APN QG/J ��[ — <br /> PARCEL SIZE G.'{Z.o r e <br /> OWVER NAME, <br /> PHDki: <br /> OWNER ADDRESS <br /> CITYlSTATFJZiP ) <br /> � CONTRACTOR <br /> CONTRACTOR ADBRESS �, CrrY/STATFJLIP !.(/ O <br /> LICENSE -42 ❑C-36/ OTHER '\UYIBER' ZZS EXPIRATIONDATE�fJ <br /> WATER TABLE DEPTH:__f/ In) It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PBRC TEST(S) NUMBER LANG USE APPLICATION#_ \ <br /> TYPE OF WORK: NEW INSTALSAT'ION O REPAIR/ADDITION ❑ ENCINEER DESIGNED/ALTERNATIVE <br /> ❑ IIEPLAGEMENT ❑ DESTRUCTION } <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COKMERCIAL OTHER <br /> Nt:MRER OP LIYINCUNfTS: NUMBER OF REDROOMS: <br /> / NUMBER O?EMPLOYEES, <br /> it SEPTIC TANK TYPE•MF A/ �1 .`^ CAPACRY_/X GO gst IS OF COMPARTMENTS <br /> CJ CREASE TRAP TYPE/MFG�_ ('APACrTy F1 gai #OF COMPAR'CMENTS 1� <br /> ❑ PKC TXPLANTDISTANCE TOHEAREST: WELL_ `- R FOUNDATION /G/ n �\ <br /> fl PROPERTY LME f <br /> (O LIFE STATION SIZE TYPE OF Pump ❑ SAND OIL SEPARATOR(ENCLOSED SVsnm) t <br /> y+� LEACH LINES ❑ LEACHING CNAMSERS #OF LINES - _ LENGTH of Lnves_ <br /> DISTANCETO NEAREST WF:T.L {.,�._ft FOUNOAT*li R PROPERTYUNE J fj <br /> ❑ FILTER BED Win= R LENGTH R DEPTH <br /> -- rt <br /> DISTAIICE T"".. WELL_ ft FOUNDATION R PROPERTY LINE }j <br /> fl MOUNDED WIDTH R LENGTH R DEPTH <br /> tt <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LIVE ft <br /> ❑ SUMPS WIDTH ft LENGTH _` R DEPTH <br /> R <br /> DiSTANCETO NEAREST WELL _ft FOL?1DAT'IOti_ R PROPERTY LINE ({ <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft Dr•.rrH__ <br /> R <br /> DISTANCE TO NEAREST WELL "� R FOUNDATION_ ft PROPERTY UNE_ ft <br /> PITS wrt1TH `R vr/ba R DEPTH �^ ft <br /> DISTANCE TO NEAREST WELL _ J 010 R FOUNDATION ,�ft PROPERTY LINE aC�� ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK tvlr.t.BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. <br /> STATE LAWS AND RULES AND REGUL VnONS OF SAN JOAQUIN COUNTY. <br /> MINI.MU. 24 HOUR ADVANCE NOTICE REQUIRED FUR IN PE IONS-PLEASE CALL(209)953-7691 ` <br /> SICNE <br /> �vI !0A. TITLE DATE <br /> 1 <br /> dh <br /> i <br /> E <br /> 1 <br /> DEPARTMENT S t)NLY <br /> Application Accepted By DaSe `'F `! Q Am. Zf Z- Employee <br /> Final Inspection 8y� <br /> _..-_ Date ___ C1 SPECIAL PERMIT-Approved by <br /> Character of Soil to Dep[R of 3 Th _ PWSUmp Soil Character: <br /> COMMENTS _/ u/ o F `^P 44 a04— SC n <br /> PE Sc Received Amount <br /> Code INFO 8 ash Remitted Date rviu R ues _ Invoice# Permit ID# <br /> �\ <br /> 42-0:-961 <br /> I21VO2 ONSITE WASTEWATER PERMIT <br />