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w <br />�O�J�✓� /L 30 <br />e ONSITE WASTE ATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL. HEALTH DEPARTMENT 304 E WEBER AVE - 3" FL- STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFVNDABLE PERMIT <br />SC <br />I:ALL (LUPI YDJ-/OY / mit rwir6l 1 tura <br />EAYI KEN I YEAR FRUM UA7 E ISSUaU <br />JOB ADDRESS <br />-M <br />In` r 1 �+ C Vi �d CIT <br />a.t�. � �4 C-0- �t-� �'1 <br />CROSS STREET FJfwNg-') <br />KtJM <br />{ZIP �1iM <br />rY/ <br />/ � <br />APN QY/-7-71y,—.2q <br />PARCEL SIZE-,•— r _ <br />OWNER NAME 3o L" <br />V irr �Q' <br />I ` <br />PHONE <br />OWNERADDRESS sffez, <br />CITY/STATE/ZIP <br />CONTRACTOR 1 I >�,l! <br />t2-�G,KS� <br />�j,'yt,,� <br />PHr/ c� <br />ONE _ J {V-- �db �&:_ <br />CONTRACTOR ADDRESS P <br />Q Q M <br />Ory S n CITYISTATEIZIP <br />M A n}' --A GIF4 9 S-3 3 <br />LICENSE ❑ C42 ❑ C-36 <br />OTHER <br />NUMBER b U tS�Dl <br />EXPIRATION DATE _ <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INPORMATION: Coordinates X Y <br />❑ PERC TEST (S) NUMBER_ LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION Q,—HEPAIR/ADDITIOY C7 EVGIAEER DESICNEDIALTERNATIYE <br />❑ REPLACEMENT ❑ DESTRUCTION <br />INSTALLATION WILL SERVE; EFRrsiDENcE ❑ CONTMERCtAL ❑ OTHER_ <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG CAPACITY gat # OF COMPARTMENTS <br />❑ GREASE TRAP TYPF/MFG CAPACITY gal # OF COMPARTMENTS <br />❑ PKC TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION ti PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR (ENCLOSEDSYSTEM) <br />9ALFACH LINES ❑ LEACHING CHAMBERS #or LINES— LENGTH OF LINES /r�, R <br />DISTANCE TO NEAREST WELL !3-AQ411 FOUNDATIO\ Il PROPERTY LINE 14131 R <br />❑ FILTER BED WIDTH ft LENGIH fl DEPTII t1 <br />DISTANCETO NEAREST WELL. _ tt FOUNDATION ft PROPERTY LINE tl <br />❑ MOUNDED WIDTH t7 LENGTH ^ ft DEPTH t1 <br />DISTANCE TO NEAREST WELL _ R FOUNDATION ft PROPERTY LINE 11 <br />O SUMPS WIDTH ft LENGTH _ Il DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE tl <br />O DISPOSAL PONDS WIDTH ft LF.NGTH _ R DEPTII fi <br />DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ SEEPAGE PITS WIDTH fl LENGTH fl DEPTH ft <br />DISTANCE TO NEAREST WELL fl FOUNDATION tl PROPERTY LINE ft <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILLBE DOVE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE. CALL (209) 953.7697 1 <br />SIGNED I � _ TITLE Cs1'71% 1-FC�¢a I' DATE <br />Ct Y <br />tl - - <br />�. L / <br />IV <br />ape <br />IN <br />DEPARTMENT USE ONLY <br />Application Accepted By Date �L -3 f G 3 Area -2-1 Employee ID#_ i7 <br />Final Inspection By Date / ❑ SPECIAL PERMIT -Approved by <br />Character of Soil ! plh t/Sump Soil Character: <br />COMMENTS <br />PE <br />SC <br />Received heck#/ <br />Amount <br />Date <br />Permit ) Invoice # Permit 1D# <br />Code <br />INFO <br />B ash <br />Remitted <br />Service Re uest#` <br />-y-.Ti.ICi <br />ll.s <br />333 <br />