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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQLIICOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE -3""FL- S' 1'O WrON CA 95202 -(209)468.420 <br />ADN-KEPUNDAHLL rLKMLI rum e.i.�rct an+.-. <br />CArIKGJ 1 YLAK FKOM UA It FNSULD <br />JOB nunarss <br />� � " / rzG <br />CI I'1!LIP <br />RFPAIR/ADDITION <br />❑ ENGINEERDL,;t(iNED/ALTF.RNATIVE <br />� <br />❑ DESTRUCTION <br />CROSS :/1'REtii <br />!~~ APV <br />INSTALLATION WILL SERVE: ❑ RESIDENCE <br />PARC'EL SIVE <br />OWNER NAMF: � <br />Gam-. aTA/ A// -r7 --A � <br />PRUNE <br />OWNER ADDRESS <br />❑ SEPTICTANF TYPUMFG_,. <br />CIT11STATE/ZIP <br />- <br />❑ GRE:ASF. TRAP TYPEIMFG <br />��- <br />gal N OF COMPARTMf NTS <br />❑ PKC TX PLANT DLSTANCETONEARm.T: WELL <br />CONTRACTOR •��- <br />G �6_"�C L'-L� L! <br />❑ LIFE STATION SIZE _ TIPROFPI'%IP <br />PHONE <br />CONTR4CTOH ADUHCSS <br />/�/Un , 9�.E'T �� __. <br />CITVISTATEI•LIP <br />DISTANCE TO NEAREST WELL <br />LICENSE U C-42 <br />❑ C-36 Own NUMBER <br />Q FILTER BED WIDTH IT LENGTH <br />EXPIRATION DATE <br />WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />❑ PERC TEST (S) NIIMBrR _ <br />I AND USE APPLiCATRT\ Y <br />TYPE OF WORK: ❑NEW INSTALLATION <br />RFPAIR/ADDITION <br />❑ ENGINEERDL,;t(iNED/ALTF.RNATIVE <br />_ <br />REFI ACF.Ni F.NT <br />❑ DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE <br />❑ COIISIER(IAI. <br />❑ OTHEk _ <br />NUMBCROF'LIVING UNITS,—, ­—_. NLMHERIH+BEDROOMS: <br />NUMBER or EMPLOYEES: <br />❑ SEPTICTANF TYPUMFG_,. <br />C.APAI7l'Y _.� <br />gal 4 OF COMPARTMENTS <br />❑ GRE:ASF. TRAP TYPEIMFG <br />CAPACIT Y <br />gal N OF COMPARTMf NTS <br />❑ PKC TX PLANT DLSTANCETONEARm.T: WELL <br />R FOIINOATION <br />it PROPER I'1- LI.IE It <br />❑ LIFE STATION SIZE _ TIPROFPI'%IP <br />❑ SAND OIL SEPARATOR (ENCLOSED SNSTEN1) <br />❑ LEACH LINES �( LEACHING CHAMBERS <br />k GF LINES T_T— <br />LLIGItI OS 7F LINEQ it <br />DISTANCE TO NEAREST WELL <br />fl FOLNDATIUI <br />ft PKOPLR I1- LINE _ Il <br />Q FILTER BED WIDTH IT LENGTH <br />Il <br />DEPIH _ IT <br />DISTANCE TO NEAREST WELL <br />it FOUNOAnoN <br />It PROPERTY LINE _ fl <br />❑ MOUNDED WIDTH _ . ft LENGTH <br />_fl <br />DEPITi— _ it <br />DISTANCE- TO NEAREST WELL <br />FOI.)X0ATION_ <br />11 PROPERTY LOVE It <br />_ _it <br />❑ SUMPS WIDTH _ 11 Lr\GTH v <br />eLb!1 fl <br />DEPI'H_.___-5I.-f-77 it <br />DIST4NC'E TO NEAREST WELL <br />it IOUNDATION <br />R PROPEK I LINE R <br />❑ DISPOSAL PONOS WIDTH IT LESC7TI1 <br />it <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />n FOUNDATION <br />11 PROPERTY LINE 11 <br />❑ SEEPAGE PITS WIITI'H It LENGTH _ <br />it <br />DEPTH <br />DISTANCE. TONEAREST WELL <br />ft FOIjN.OATR)N <br />fl PROPERTY LINE !1 <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION FN AND THE WORE WILL BE DONE M ACCORDANCE WITH SAN JOAQLIN COUNTI' ORDINANCES, <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQVIN COLI'r <br />'. <br />NiLM UN 24)URADIENOTICF- RF.QUIEI F.D FOR I\SPE:CTIC)N'S-PLE.ASF: <br />C':\h1. t?D'lj yq3-76vT <br />SIGNED / �.G 't- <br />_ 'IITLE <br />ATE <br />COMMENTS 4 t c [•Ly i Stge_ -J <br />PE SC Received CheckAl An. nlDare '~- Invoice $0 Permit HD <br />Code [SP0 Br ash Remitted Service Re uest4 <br />42.01.001 <br />11-2,02 ONSIIE WASTEWATER PERMIT <br />=, <br />M <br />