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V <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET- STOCKTON CA 95202 - (209) 468-3420 <br />NON-KEFUNDABLE PERMIT }� AUALL LU`J V53-fibUf FOR INSPECTIONS }�.� LXPIRES 'I YEAR FROM DATE ISSUEI <br />JOB ADDRESS Irl 4Q e4 ,. 1314 R'�riY AVF .1 CITY/ZIP �1 V�� -!S" <br />CROSS STREET {JW?11T'r..R-410-0 APN I �A'r� 3 ^ 2. T -O _ 12- PARCEL SL7E 0 -,q,+ A - <br />cthftl- <br />OWNER NAME T 9-0&Tr )Ne' j K+YVS 1 �I U� y� `-, ` ti.ti1& V1T PHONE <br />OWNER ADDRESS SAME CITY/STATE/ZIPp c <br />CONTRACTOR L1dE otw- 6eOcNY1/-oNWrleNTAL '3 3Lo - o 2 . 7^],.5T <br />CONTRACTOR ADDRESS +o-+ w. O p<K- ST. CITY/STATE/ZIP :r0'V1, C N frT���L <br />LICENSEC-42 I..0-36 OTHER NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br />F)( <br />PERC TEST # BUILDING PERMIT # <br /># OF LINES LENGTH OF LINES It <br />LAND USE APPLICATION # <br />TYPE OF WORK: I NEW INSTALLATION <br />REPAWADDITION <br />ENGINEER DESIGNED /ALTERNATIVE <br />WIDTH ft LENGTH <br />II REPLACEMENT <br />II DESTRUCTION <br />INSTALLATION WILL SERVE: I RESIDENCE <br />COMMERCIAL <br />1 OTHER <br />WIDTH ft LENGTH <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ <br />SEPTIC TANK TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ DISPOSAL PONDS WIDTH It LENGTH <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES It <br />Permitt Invoice # Permit ID# <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION It PROPERTY LINE It <br />❑ FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />. -2 <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE It <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />I ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION It PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH It LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION It PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH It <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION ft PROPERTY LINE It <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS AND RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINIA�JsW"44 HOUR ADVANCE NOTICE REQUIRED <br />FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED <br />/ <br />/—'L <br />G <br />TITLE CCN VCTFWT DATE <br />R qy�%F <br />F FcFOV�Vr <br />Fs 13Qlo <br />F® <br />°Fpr A/ <br />MFHr <br />DEPARTMENT USE ONLY w W <br />Application Accepted BV / I/ I/' Date,-/,(�– 1 �3 t"1 � /9 Area %�r �/ Employee ID# <br />Final Inspection By Data ! TC SPECIAL PERMIT - Approved by <br />Character of Soil to De of Ft: PiVSump Soil Character: <br />C MMENTS Q 7 /,;II -- n n 'I <br />A (1t? Ir ; ✓1 r,�n <br />PE <br />Sc Received Chec <br />Amount Date <br />Permitt Invoice # Permit ID# <br />Code <br />INFO B ash <br />Remitted <br />Service Re uest# <br />�a1 <br />. -2 <br />1 1L 211311 <br />� - <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />