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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> 1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468.3420 <br /> t NON-REFUNDABLE <br /> PERMIT �CCA�LL 209)9533-7697 FOR INSPECTIONS .t�EXPIRES 1pYEAR FROM DATE ISSUED <br /> JOBADDRESS 390ll �' CMr? p^J Ap• CITY/ZIP kcA �Po ! Z'�'� ' <br /> CROSS STREET V• • r0 •"67C APN 00--/4S_ I ' PARCELSRE O'�� IR-• p <br /> �^ 0 <br /> OWNERNAME h'lEy �tniN Gom�Z PHONE <br /> OWNER ADDRESS 2 4 t�3-Z N, ELL-107-rr-D CTY/STATEZP fcefpiPo So <br /> A 9T7-2-0 <br /> CONTRACTOR WVC ` F PHONE 3'VI9-03 + <br /> CONTRACTOR ADDRESS I[O} wA)e- !�-rCITY/STATE/ZIP `01>1Gp <br /> LICENSE C.0-42 QC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST #----L- I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: !❑ NEW INSTALLATION L, REPAWADDITION l I ENGINEER DESIGNED/ALTERNATIVE <br /> J REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: F RESIDENCE 1 COMMERCIAL I 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 ft FOUNDATION It PROPERTY LINE ft <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 It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <br /> ❑ MOUNDED WIDTH It LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It 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 /> M IMU/M)/d�7fQ/UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED //� C TITLE DATE <br /> Y�F�►T <br /> ��VFD <br /> 9 ?419 <br /> i <br /> COU <br /> Mri <br /> s FiyT�TY <br /> TMENT <br /> DEPARTMENT EON Y <br /> Application Accepted py Date Area Employee ID# <br /> Final Inspection By Date ] SPECIAL PERMIT-Approved by <br /> Character of Soil to, pth of 3 Ft: / > 6. Pit/Sump Soil Character: <br /> COMMENTS y fr �I�L VJ D I� ✓a i 0•G �t n / i ry C k . li 11 <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B emitted Date Service Re ues # Invoice# Permit ID# <br /> lr42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />