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k <br /> ONSITE WASTEWATER TREATMP-N SYSTEM FERMI : gy <br /> SANJOAQVINCOL ;:NVIRONMENTAL HEALTH DEPARTMENT EWEBER AVE-3-Ft,-STOCKTON•CA" 20Z_'-,(211q)96&•+fZU <br /> NON-REFUNDABLE PERMIT CALL 209 95,34697 FOR INSPECTIONS EXPIRES I YEAR FROM fDATE ISSUED <br /> JoBADDRESS � • n / --. CITYizIp Il 0 Z' <br /> CROSS STREET � t�'�"" � All 0 • �f S/• / PARCEL E <br /> ' l SIZE. <br /> OWNERNAME G iZ.�F�LG'\ PHONEC � lC?ZI <br /> ` k OWNERADDRESS CTIY/SCATElZIP <br /> CONTRACTOR -�{4-R.i�vj- -{r'i 1.t�. PHONe -a_O <br /> 1 <br /> CONTRACTOR ADDRESS 1 CITY/STATEIZIP _ <br /> LICENSE ❑C-12 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOCRAPHICALIM:ORMATION: Coordinates X Y <br /> ❑ PERC TEST # 8UlL➢TNG PERMIT# -1 <br /> 'AND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIRIADDTTION CJ ENGINEER DESIGNED/ALTERNATIVE <br /> a REPLACEMENT U DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE O COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNrrs, NUMBER OF BEDROOMS: / NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYP£IMFCG U V,t ROM- tl�� CAPACITY G G gal #OF COMPARTMENTS <br /> 1� <br /> ❑ GREASE TRAP TYPFIMFG CAPACITY gal 0OFCOMPARTMENTS K, <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) 1 <br /> LEACH LINES L1 LEACHING CHAMBERS #OF LINES LENGTH OF LINESvol ft <br /> DISTANCETO NEAREST WELL $I'4- tt FOUNDATION LJI It PROPERTY LINE r�Q' R <br /> ❑ FILTER BED WEDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDYH ft LENGTH ft DEPTH it <br /> DISTANCE To NEAREST WELL It FOUNDATION R PROPERTY LINE ft <br /> © SUMPS WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL It POUNUATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCETO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> f� SEEPAGE PITS NuMBE11 1''„�,_,_._weoTs mm, 1raIt DEPTH : �, ft <br /> DISTANCE TO NEAREST WELL /2!� ' ft FOUNDATION JS It PROPERTY LINE /O -_It IAV} <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL{209)953-7697 <br /> SIG �1 <br /> TITLE <br /> DATE <br /> f <br /> i <br /> 1 <br /> t <br /> I y.. <br /> jl <br /> �I <br /> 37 <br /> ' I Y U <br /> �.. <br /> t. T M <br /> �. <br /> r <br /> L-1 EPARTMENT U ONL <br /> Application Accepted BDate Area Employee IDN <br /> Final Inspection B - . Date �� i` ❑ SPECIAL PERMIT-Approved by l <br /> Character of Soil to p of 3 F7• PWSDInp Sail Chancier: <br /> COMMENTS <br /> PE SC ReceiveedC6ecldl_ Amount Date Permitl Invoice# Permii ID# <br /> Code INPD By Cssh Relydtied Service Request# <br /> 41 ONSITE WASTEWATER PERMIT <br />