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3,11 <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209}468-3420 <br /> NON-REFUNDABLE PERMIT �C+ALL 209 953-7697 FOR INSPECTIONS /EXPIRES 1 YEAR <br /> rFROM DATE ISSUED <br /> JOB ADDRESS 5 ' ' V� CITYIZIP � f"�--Adv �F- 11 '2-15 Z <br /> CROSS STREET L L� ' O 1 APNf2a-1"1 V G —PARCEL SIZE_ V <br /> OWNER NAME { Af�'IJ�� q1`14-x=}�� Z��� -,PH_O�N�E�_ <br /> OWNER ADDRESS Lk "o, k-%j CITY/STATEIZIP <br /> CONTRACTOR t�' C `-�� 9"-j`� PHONE� -'>� cU —S <br /> 11 �.. <br /> CONTRACTOR ADDRESS �5© lam]�Z-YZL.--�L' l G} �/7 ClTY1STATEIZJ.P _ ^�\y'✓ ''C/��'1 �� 5 <br /> LICENSE/(C-42 IAC-36 OTHER NUMBER S-� r 57.5EXPIRATION DATEy <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIRIADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT - DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE :1COMMERCIAL 2 OTHER <br /> NI.JMBER 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 It PROPERTY LINE ft <br /> D LIFT STATION SIZE TYPE OF PUMP El PKG TX PLANT 7 SAND OIL SEPARATOR(ENCLOSED SYSTEM) (� <br /> 66-1 LEACH LINES LEACHING CHAMBERS #OF LINES � LENGTH OF LINES 40 h <br /> DISTANCE TO NEAREST WELL �thJ ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL _ ft FOUNDATION ft PROPERTY LINE _ ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> LJ DISPOSAL PONDS WIDTH It LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL fit FOUNDATION ft PROPERTY LINE ft <br /> i r ft <br /> SEEPAGE PETS NUMBER ,� WIDTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <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 REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUrA-4 HOLYR ADVANCE NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL(209)953-7697 /c <br /> SIGNED -A— TITLE_fD \[/bI) 2- DATE 0/15;✓am r 13 <br /> LL <br /> f(. 1 <br /> II <br /> 1' <br /> Cp <br /> +- I -- .1,ba+ 2� ­ `-�, <br /> C <br /> 1 <br /> '-% a <br /> k. - <br /> +1 —LL A� IQ <br /> I <br /> I`t Z-° <br /> F <br /> DEPARTMENII USE JDNLY <br /> Application Acce : Date! r Area Employee ID# <br /> Final Inspection - Date / Z=? ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to epth of 3 Ft: PittSump Soil Character: <br /> COMMENTS <br /> PE SC Received heck Amount Date Permit! Invoice# Permit ID# <br /> Code INFO B as Remitted Service Request# <br /> 0 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 1014107 <br />