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Application Accept <br />Final Inspection By <br />■■■■■■■■■■■m■■■■■rm■■■■■■■■■ <br />tvw� <br />� 11 SPECIAL PERMIT - Appro�ed by <br />_. _. . <br />7 <br />AL <br />/rC-, <br />42-02-001 - ONSITE WASTEWATER PERMIT' <br />I Y2212003 <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER Ave rY- FL -7'&V' CA 95202 - (209) 468-3420 <br />NON-REFUNDAB <br />AMIT-- ALL (209) 951,7fa7 <br />FOR INSPECTIONS EXPIRES I YEAR FROM DATC ISSUED <br />JOB ADDRESS <br />�PV 124 <br />if <br />CITY//qZ7I�Py1-, <br />�_� <br />CROSS STREET <br />n/� /KQ <br />�2 4. /w^,1 �r-` <br />1 �% n^(y� <br />�/ API P,55�r C90 -3 PARCELSIZE 1 o 2-5 <br />,A�V�\O/y, <br />OWNER NAME �p <br />1-2 <br />/'>i(�'1�/ CSI A� Div ��/C+� <br />l%V PHONE $ 55 -0303 <br />OWNERADDRESS <br />DISTANCE TO NEAREST <br />'CITY//Sy7TATF/ZIP <br />CONTRACTOR <br />❑ <br />\ �� PHONE <br />CONTRACTOR ADDRESS <br />DEPTH ft <br />CITYJSTATEJZAP <br />DISTANCE TO NE REST <br />W LL ft FOUNDATI F <br />LICENSE 'C-42 <br />❑ C-36 OTHER ! <br />NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # <br />BUILDING PERMIT #_ <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />❑ NEW INSTALLATION <br />REPLACEMENT <br />REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br />❑ DESTRUCTION <br />INSTALLATION WILL SERVE: .�„ RESIDENCE <br />❑ COMMER OTHER <br />NUMBER OF LIVING UNITS: UMBEROF BEDROOMS: r:4�=N BER OF EMPLOYEES: <br />SEPTIC TANK <br />1 <br />;TYPF,/MFG o .L <br />CAPACIL. _I 6 00gal #OFCOMPARTMENTS <br />❑ ' GREASE TRAP <br />TYPEIMFG <br />CAPACITY gal # OF COMPARTMENTS <br />❑ 'PKC TX PLANT <br />DISTANCE TO NEAREST: WELL <br />R FOUNDATION ft PROPERTY LME It <br />❑ LIFT STATION <br />SIZE —TYPE OF PUMP <br />❑ SAND OIL SEPARATOR (ENCLOSED S� <br />Application Accept <br />Final Inspection By <br />■■■■■■■■■■■m■■■■■rm■■■■■■■■■ <br />tvw� <br />� 11 SPECIAL PERMIT - Appro�ed by <br />_. _. . <br />7 <br />AL <br />/rC-, <br />42-02-001 - ONSITE WASTEWATER PERMIT' <br />I Y2212003 <br />LEACH LINES _. <br />LEACHING CHAMBE <br />. 3 6 FLINES <br />LENGTH OF LINES <br />DISTANCE TO NEAREST <br />WELL + ft UNDATION= + <br />ft PROPERTYLINE� ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH ft <br />DEPTH ft . <br />DISTANCE TO NEAREST <br />WELL; ft FOUNDATION <br />R PROPERTY LME ft <br />❑ <br />MOUNDED _ <br />WIDTH R LENGTH It <br />DEPTH ft <br />DISTANCE TO NE REST <br />W LL ft FOUNDATI F <br />R PROPERTY LME ft <br />SUMPS <br />WIDTH <br />_ <br />ft LENGTH R <br />DEPTH ft <br />DISTANCE TO NEAREST <br />L ft FOUNDATIO \ -T <br />R PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH - <br />ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL R FOUNDATION <br />R PROPERTY LME It <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH ft <br />DEPTH fl <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION <br />ft PROPERTY LINE fl <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY , <br />ORDINANCES, STATE LAWS AND RULES AND REGULATIONS SAN JOAQUIN <br />COUNTY. <br />M INIjM_ 2 tt <br />rOF <br />OTI E REQUIRED FOR IN P ONS - PLF: - <br />(209) 953-7697 <br />SIGNED <br />J1 Qr,/��Aj JI l/ <br />� 4 TLE <br />DATE <br />Application Accept <br />Final Inspection By <br />■■■■■■■■■■■m■■■■■rm■■■■■■■■■ <br />tvw� <br />� 11 SPECIAL PERMIT - Appro�ed by <br />_. _. . <br />7 <br />AL <br />/rC-, <br />42-02-001 - ONSITE WASTEWATER PERMIT' <br />I Y2212003 <br />