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ONSITE WASTEWATER TREATMENT SYSTEM T <br />\UMBER OF BEDROOMS: <br />NIMBER OF EMPLOYEES. <br />TPERMIREET - NCA95202 (209)468-3420 <br />600 E <br />TYPFlMFG�, <br />SAN JOAQUIN COUNTY ENVIRON>IFNTAL HEALTH DEPARTIENT <br />EXPIRES I YEAR FROM DATE ISSUED <br />gal # OF COMPART'NE.\TS <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR 1%sPECTlONS <br />TYPEIMFG <br />LI <br />CtTI��'I7.IP �9s2_ <br />pi # OF COMPARTMENTS <br />/7 _ <br />JOB ADDRESS - <br />PARCELSIZE� <br />WELL <br />` <br />APN <br />p <br />CROSS STREET At5r _ <br />TYPE OF PUMP <br />A <br />0 SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />PHONE q-27 <br />Ll LEACHING CHAMBERS <br />OWNER NAME C 75-17+141.6-1 i� <br />LENGTH OF LINES =f O L1 <br />q'Y7A >C 1 �AA. AA12S <br />CITY/STATE,'ZIP Iifh i' ('A 95z& <br />ft FOUNDATION <br />OWNER ADDRESS <br />O FILTER BED <br />WIDTH <br />CONTRACTOR _ <br />PHONE <br />DEPTH ft <br />CONTRACTOR ADDRESS <br />c CITY/STATE/7.IP <br />`p <br />LICENSE 0 C-42 0 C-36 <br />NUMpER E%PIRATION DATE <br />Q�\p <br />WATER TABLED � pG <br />Ct <br />MPv.INFORMATION: Coordinates X \' <br />ft LENGTH <br />0 # <br />LAND USE APPLICATION # <br />PERC TEST <br />TYPE OF WORK: N' 1� Q��\' <br />0 REPAIR/ADDITION ENGINEER DESIGNEDIALTERNATTVE <br />WELL <br />ft FOUNDATIONR% <br />0 DESTRUCTION <br />INSTALLATION WILL: RYEE`,4 RFsiDF.NCE <br />O COMMERCIAL O OTHER <br />_ It LENGTH <br />NUMBER OF LIVING 0\17rS' <br />\UMBER OF BEDROOMS: <br />NIMBER OF EMPLOYEES. <br />SEPTIC TANK <br />TYPFlMFG�, <br />CAPACRY __ <br />gal # OF COMPART'NE.\TS <br />O GREASE TRAP <br />TYPEIMFG <br />CAPACITY <br />pi # OF COMPARTMENTS <br />DISTANCE TO NEAREST: <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />O LIFT STATION <br />SIZE <br />TYPE OF PUMP <br />O PKG TX PLANT <br />0 SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />Ll LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES =f O L1 <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />O FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE. TO NEAREST <br />WELL <br />ft FOUNDATION <br />fi PROPE fi <br />O MOUNDED <br />WmTe <br />ft LENGTH <br />ft <br />fi <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATIONR% <br />ME ft <br />10, SUMPS <br />1 <br />WIDTH �� _ <br />_ It LENGTH <br />I <br />EPTH 1 ft <br />DISTANCE TO NEAREST <br />WELL <br />0 DISPOSAL PONDS <br />Wmrtl <br />It LENGTH, <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />fl FOUNDATLNc a <br />1II.r`1' Ut P, ft <br />O SEEPAGE PITS <br />NUMBER <br />WIDTH <br />P.,�1 Cid <br />Lh� ft <br />DISTANCE TO NEAREST <br />WELL. <br />ft FOLitM _ _n''Cl -. _ <br />�1. O PROPERTY LINE <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WOR)�-*H.L BE DONE IN ACCORDANCE WITH SM' JOAQUIN COUNTY <br />ORDIN4NCFS, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />EPARTMENT SE ON <br />Application Accept4a� ate'` Date Area Employee ID# <br />Final Inspection By Date 0 SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMME-,TS Ow l'of c.F ft-agfl <br />PE SC ReceivedAmount Date Permit/ Invoice # Permit IDN <br />Code INFO BY r9c".,W,-emitted Service R uect a <br />42-01 ONSITE WASTEWATER PERMIT <br />051GQao7 <br />