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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT 1CALLw 1209 953-7697 FOR INSPECTIONS G �7ZEXPIRES'I YEAR FROM DATE ISSUED <br /> Q; <br /> JOB ADDRESS -I TO I • �'�Tr�1'`� �• CITY/ZIP C-A LO / 2-CD <br /> Z�� jam. -1 <br /> CROSS STREET V L L12-E N APN �'�-13o-3`-f +_3 PARCEL SIZE 3 I '" p <br /> r c <br /> OWNER NAME Joc 13A%j A9-0 PHONE—El J 14A4 }n <br /> OWNER ADDRESS R C)• ►3c% ;--4 CITY/STATE/ZIP FSGA-L-O^J C t IF3-2,0 <br /> CONTRACTOR WV Dr,F Gf-0ENV)'Q0,JMCNTrkL- PHONE ala9- 034 <br /> CONTRACTOR ADDRESS N� D ST- CIN/STATEIZIP LD D I CA ys'y f <br /> LICENSE C-42 IC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> X PERC TEST # Z- BUILDING PERMIT# LAND USE APPLICATION# PA-I B 001 q <br /> TYPE OF WORK: - NEW INSTALLATION ___ REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL L OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL It FOUNDATION ft PROPERTY LINE It <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL It FOUNDATION ft PROPERTY LINE ft PA <br /> L3MOUNDED WIDTH ft LENGTH ft DEPTH ft �/1 Nr <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE It r -�/�^ <br /> ❑ SUMPS WIDTH ft LENGTH It DEPTH It V C� <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE � AQV N ?019 <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH r <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINET OF MFI�Tq N7�• <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, �RTMFNT <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> �IMU"HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 G <br /> SIGNED TITLE C.6AISVLTfi7V DATE <br /> AVENUE a'dNF7E <br /> •- 1 —__— _ �� <br /> 1� Ilil wm.w. <br /> K , <br /> i <br /> II �. <br /> ++� <br /> I — � �- = 911 — -_ • _ _, �,I�� <br /> III �a <br /> a i v <br /> DEPARTMENT U E-O Y /yy <br /> Application Accepted By Date Z "1 Area _! Employee ID# <br /> Final Inspection By Date J SPECIA PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check Amount Permit/ <br /> Code INFO B ash Remitted Date Service Re uest# Invoice# Permit D# <br /> 0_G --? <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />