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QNSI N E WASTEWATER TREATMENT SYSTEM 09ERNTI <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.FIAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> BION-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> -JOB ADDRESS y(_t82C c) 0-3 PIZ. CITY/ZIP S OLt<- t)ry J.Sz.�Z <br /> CROSS STREET EJ A Z2W C-1:- R APN PARCEL SIZE Iy <br /> d <br /> OWNERNAME ��I+Afii] JETTL OF� PHONEn <br /> OWNER ADDRESS <br /> E CITYISTATE/ZIP <br /> CONTRACTORJ--r PHONE <br /> CONTRACTOR ADDRESS gs7"J -f77C1r Rsso•-1 e12-55KIi?_ -(l i-e Zo, CITY ISTATE/L'IP �LR�•"'t`Y� �H- c7�g ZS <br /> LICENSE del/-12 ❑OC-36 OTHER NUMBER 122y.�i t° EXPIRATIONDATE <br /> (NATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATON: Coordinates X Y <br /> ❑ PERC TEST # F BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: U NEW INSTALLATION REPAIRIADDITION U ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY /S-3o gal #OFCOMPARTMENTS Z- <br /> • GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> • LIFT STATION SIZE TYPE OF PUMP ElPKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM), <br /> LEACH LINES ffIZLEACHING CHAMBERS ' / r� r #OF LINES I LENGTH OF LINES S�I It <br /> DISTANCE TO NEAREST WELL 110e7 <br /> Iyc w..h8 FOUNDATION Zb� ft PROPERTY LINE .5 ft <br /> • FILTERBED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> EI MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL fl FOUNDATION It PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Gl DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> kirl,SEEPAGE PITS NUMBER WIDTH ,�� ft DEPTH 2S ft <br /> DISTANCE To NEAREST WELLA1O lafolt FOUNDATION Zo ft PROPERTY LINE S I 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 /> MINIMUM Ya H DVANCE NOTICE RE•UIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGIJED TITLE!P`� + t n1T- DATE $�I'I <br /> N <br /> DEPARTMENT US QONLY Su— <br /> Application Accepted By Date Area ployee ID# <br /> Final Inspection Dy i ' Date ❑ SPECIAL PERMIT-.Approved by <br /> Characterof joil t D l4p T of 3 Ft* It/Sump Soil Character: <br /> COMMEI 1 S <br /> PE Sc Received heck Amount Permit/ <br /> Code I FO B ash Remitted Date Service e e t# Invoice# Permit ID# <br /> u2z4 <br /> 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24112 <br />