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ONSITE WASTEWATEREATMENT SYSTEM PERMIT <br /> FeArl JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT d 364 E WEBER AVE-3"°FL-STOCKTON CA 9520. J9)468-3420 <br /> NON-REFUNDABLE PERMIT CALL. 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> - <br /> CITY/ZIP <br /> OR ADDRESS <br /> m <br /> H �ROSSSTREET �^ '•"'-�T�" =!Y- APN '�L'- Z - PARCEL SIZE_I !';Ci-� v <br /> I 4 IVy PHONE <br /> OWNER NAME m <br /> M <br /> WNEaADORLss 'z - - 4 CITYISTATE/ZIP <br /> f^7 �" � - - � 4 <br /> I HONTRACTOR l�•JG't � PHONE ,)1 <br /> CONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER ERPIRATION DATE J, <br /> II <br /> M NATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> Q PERC TEST # �I BUILDING PERMIT# LAND USE APPLICATION# �'A - I? <br /> TYPE OF WORK: ❑ NEW INSTALLATION Q REPAIRIADDITION ❑ ENGINEER DESIGNED IALTERNAT[VE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: - <br /> ti I <br /> rte❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS ,. <br /> A ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> �❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LME ft _ <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) { <br /> i <br /> FU LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO N EAREST WELL it FOUNDATION ft PROPERTY LINE R <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH fl t <br /> FODISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft' <br /> QSt1MP5 WIDTH ft LENGTH ft DEPTH it 1 <br /> f <br /> Flu <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft !{ <br /> ❑ SEEPAGE PITS Numnea WmTH it DEPTH ft E <br /> L DISTANCE TO NEAREST ` WELL R FOUNDATION ft PROPERTY LINE ft EI <br /> I HEREBY CERTIFY THAT 1 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 /> SIGNED '�, -1 Y11h'IM11UM 24;Ol1H ADVANCE NOTICE Rk:QU1RED FOR97 <br /> IN PECTIONS-PI.F:ASE CALL{269}y5}-DA7E <br /> LL <br /> MEOWF 1.. <br /> FME + <br /> r: sew <br /> J '. I! �k <br /> i <br /> I ..A. <br /> p� <br /> DEPARTMENT U E QNLY ►/� + <br /> �.cApphwtlDn Accepted By t r - Date�- s' Area Employee IDA <br /> �a <br /> ti. r q <br /> k Finak.lnspection By '�+ - ` mate d SPECIAL PERMIT Approved hy <br /> Character of Sod to Depthoptir -:PIUSump Sol Character + 1 - <br /> Cbm 41ENTS s <br /> Is 'FrFf"S Sq <br /> 11 •.t rq <br /> PE -SC`' Received Chec a Amount' Permitl- <br /> Code INFu B ash -'Remitted ..� Daie 'Service'Re uejjst#Y Invoice# Permit III - <br /> 4 Sas �S. <br /> ..s 42-62-DOl ., ONSITE WASTEWATER PERMIT <br /> 12a2aOD3 <br />