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�I <br /> SCANNED <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM ENT 304 E WEBER AVE-3k"FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFLNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> I1 JOB ADDRESSdS /_]lM S7'� F-I A.C7 C[TYIZ1p �s ��L} <br /> 7- <br /> I - CROSS STREET APN <br /> �-i� PARCELSSIZE <br /> ` OwNERNAMe !��� a�r"1' /7Gr lvG,.' PHONE <br /> f o <br /> �{ OWNER ADDRESS � � CITYISTATE/ZIP A4 e - <br /> 4 CONTRACTOR E '� PHONE r' 4/.-7 <br /> CONTRACTORADDRESS r L 4 art"� CITYISTATIULIP e <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE � <br /> s WATER TABLE DEPTH: R GE OCRAPHICALINFORMATION: Coordinates X <br /> i Y ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: A NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNEDIALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> 4 � ENSTALLATION W[LL SERVE: � RESIDENCE ❑ COMMERCIAL ❑ OTHER f{y <br /> II NOMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: � NUMBER OF EMPLOYfBS: � i <br /> SEPTIC TANK TypvMFp, G CAPACITY gal #OFCOMPARTMENTS <br /> 1+ ❑ GREASE TRAP TYPEIMFG �t CAPACrn" 981 #OPCOMPARTMENTS <br /> ❑ PKC,TX PLANT DISTANCE TO NEAREST. WELL /CI• R FOUNDATION ft PROPERTY LINE 1'-I.sJ fi <br /> - ❑ LIFT STATION SIZE TYPE OF PUMP O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS / Z #OF LINES c'� LENGTH OF LINES Y C)_ _ ft <br /> F�j <br /> DISTANCE TO NEAREST WELL ( s3J R POUNDAT]ON R PROPERTY LINE ft <br /> ❑ FILTER BED WMTK ft LENGTH - R DEPTH R <br /> `. <br /> I� DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> 1 ' ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> r DISTANCE TO NEAREST WELL ft FOUNDATIO ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH_ 'Z , R LENGTH / :2T R DEPTH Ic'7 r _ ft <br /> DISTANCETO NEAREST WELL /r-)' fl FOUNDATION R PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH fl DEPTH {1 <br /> 3 II DiSTANCETO NEAREST WELL ft FOUNDATION Z-r}� ft PROPERTY LINE /7 R <br /> _J ❑ SEEPAGE PITS WIDTH fl LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FUUNDATioN ft PROPERTY LINE R <br /> t4�-- I HEREBY CERTIFY THAT[HAVE PREPARED THIS APPLICATION AND THE WORK WILL HE DONE IN ACCORDANCE WITH SAN JOAQUV4 COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> P INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> I <br /> SIGNED TITLE y_-���'(/ DATE <br /> 4 I <br /> FI <br /> ' L <br /> ! <br /> FIJI v P, P <br /> DEPARTMENT U E O. Y /f EN`flHU <br /> Application Accepted By DateJ` Arra1-_ EmPlDyce ID# <br /> Final Inspection By - Date -- ❑ SPECIAL PERMIT-Appmvcd by S/9F <br /> d Cha ratter of Sail tp th of3 PltfSump Soil Character: <br /> COMMENTS <br /> ' PE SC Received heck# Amount PermiU <br /> Date invoice# Permit lD# <br /> Code INFO B ssh Remitted Service Re uest# <br /> l-O <br /> �i <br /> 42-01-001 ONSITE WASTEWATER PERMIT <br /> 127102 <br />