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ID.1ao <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQVIN COUNTY ENVTRONMEN-FAL HEALTH DEPAR'I�AtENT a 304 E WEBER AVE -3" FL- STOC:KTONCA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 943-7697 FOR INSPECTIONS EXPIRES I YEARFROMDATE ISSUED <br />JOB ADDRESS ( � aI1 < C 1 L-t4.y tc AP4 _ q CITYiZIP �'�C )b l Cyr <br />CROSS STREET t4 C IL--- , J� ,koj APN / � � V � " PARCEL SIZE <br />OWNER NAME hh tt `w- .. PHONE <br />OWNER ADDRESS CITY/STATEIZIP <br />CONTRACTOR _ t I l� GGK�4"�-� 'rl'C C L PHONE �'j - FGCv <br />CONTRACTOR ADDRESS Cs CITYISTATE/ZIP <br />LICENSE. ❑ C-42 ❑ C-36 OTHER NUMBER EXPIRATION DATE. <br />WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X V <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # _ <br />TYPE OF WORK: ❑ NEW INSTALLATION X REPAIR/ADDITION ❑ ENCI!SEER DESIGNED !ALTERNATIVE <br />❑ REPLACEMENT ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: D- MSIDENCE ❑ COMMERCIAL LI OTHER <br />NUMBEROF LIVING UNITS: NUMBER OF BEDROOMS: NUMBEROFEMPLOVEES: <br />❑ SEPTIC TANK TYPE/MPG_,,,,____„_....... _ _ CAPACITY _ gal # OFCOMP.ART'MENTS_ <br />❑ GREASE TRAP TYPE/MFG.-_- ,,,,_,_ CAPACITY gal # OF COMPARTMENTS <br />❑ PKC TX PLANT DISTANCE: TO NEAREST: WELL _ ft FOUNDATION _ , ft PROPERTY LIKE ---- <br />CI <br />_-❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />U LEACH LINES ❑ LEACHING CHAMBERS t # OF LINES LENGTH OF LINES L'10 ft <br />DISTANCE TO NEAREST WELL S'bI III FOUNDATION t� I ft PROPERTY LINE lo. ft <br />❑ FILTER BED WIDTH ft LENGTH ,ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH _-ft LENGTH ft DEPTH _ _ ft <br />w" <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />I{Y SUMPS WIDTH _ ft LENGTH Ia 1 ft DEPTH A I ft <br />DISTANCE TO NEAREST WELL­�!3,NE It FOUNDATION _US! ft PROPERTY LINT KIr---R <br />❑ DISPOSAL PONDS WIDTH ____ft LENGTH ft DEPTH R <br />DISTANCE TO NEAREST WELL ft FOUNDATION_ ft PROPERTY LINE R <br />❑ SEEPAGE PITS NUMBER W'IDnIft DEPTH tt <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ._ft <br />I HEREBY' CERTIFY' THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br />ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINIMUM 24 HOUR ADVANCE NOT'IC:E: REQUIRED FOR INSPECTIONS - PLEASE: CALL (209) 953-7697 <br />SIGNED TITLE G(i� f f C<j-DC DATE �`i 6 <br />__ <br />rn <br />=a <br />R <br />O <br />A <br />r <br />DEPARTMENT USP )NL ' <br />Application Accepted B -..._.. Date , � �, Area Fmployoe ID# <br />Final Inspection BV _ — Date ❑SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: _ Pit/Sump Soil Character: <br />COMMENTS & 7�i - - - — <br />PE SC I Received Cheek# Amount Date Term¢/ Invoice # Permit IDN <br />Code INFO By 1 Cash Remitted Service Request # <br />42-02-001 �� ONSITE WASTEWATER PERM[ F <br />12/22:2003 <br />