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r{e�^ ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> II f SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,-3"FL-STOCKTON CA 95202 -(209)468-3426 <br /> i NON-REFUNDABLE PERMIT CALL(209)9$3-7697 FOR INSPECTIONS EXPIRES I YEAR FROM HATE ISSUED <br /> fi JOB ADDRESS 3931 N t-ACM e N 1 S CITVIZIP "I <br /> S i m <br /> `` /� /�■ a <br /> CROSS STREET y IAY'NT_/�'AW e _ _ APN "� j PARCEL SIZE fv Ck <br /> 0 <br /> y, 1. <br /> OWNER NAMEOM <br /> } 1 PHDNe bq 7 <br /> OWNER ADDRESS 2/ k)0, nX 0-340 CITYISTATFJZIP�O<< ~ i'6 yC14�5-92 <br /> y CONTRACTOR W PHONE r. <br /> V <br /> CONTRACTOR ADDRESS CITYlSTATEIZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X <br /> Y <br /> ❑ PERC TEST(5) NUMBER <br /> LAND USE APPLICATION# <br /> TYPE OF WORK: 'A NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEERDEStGNFWALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> } INSTALLATION WELL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBEROF LIVING UNITS: NU BER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> r; <br /> SEPTIC TANK TYPEIMFG 1-G I ati: 'f CAPACITY 1,-_ Bal ft OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal 4 OF COMPARTMENTS <br /> r <br /> ' L1PKG TX PLANT DISTANCE TO NEAREST: WELL4 R FOUNDATION R PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> E f <br /> } e I& LEACH LINES ElLEACHING CHAMBERS ik OF LINES L$NGTH OF LINES {O ft <br /> F DISTANCE TO NEAREST WELL ��� R FOUNDATION ' ft PROPERTY LINE R <br /> I <br /> Q FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> f ❑ MOUNDED WIDTH R LENGTH R . DEPTH ft <br /> DISTANCE TO NEAREST WELL A FOUNDATION—ft PROPERTY LINE fl {� <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft -4 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I C] DISPOSAL PONDS WIDTH ft LENGTH ft DVVTH It ? <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> O&Fl <br /> W SEEPAGE PITS WIDTH fl ErtT4— ft DEPTH �� R <br /> • � <br /> DISTANCE TO NEAREST WELL�/--,D - R FOUNDATION ] ft PROPERTY LINE fl <br /> k 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. .I <br /> MINIMUM24477H�_ODUR ADVANCE NOTICE REQUI RED FOR INSPECTIONS-PLEASE CALL(2091111-1691 ?SIGNED <br /> q �t TITLE 1A)LL= DATE ` <br /> s <br /> L G <br /> n. L <br /> �t I <br /> r <br /> iF <br /> V <br /> F /I <br /> .,f .��,�DEPARTMENT USE ONLY ,,1Application Acee Date -T -2--7 Area 21-2— Employee IDNy'/Fina{Inspectio B Date_ ❑ SPECIp�J/,I'ERA71T-Approved by <br /> 1 Character of Sail to Depth f 3 Ft: PitlSump Sail Character: / <br /> COMMEINTS t10-030,5-D12— .3 13ill-LM P"-,t . TpK. i 3 .� /112 _/ 1u't <br /> z <br /> - � <br /> - l - i <br /> Efff ' PE SC Received Amount Permit/ In Ice P r it IPN <br /> Code lNPO 6 Cash Remitted ate Service Re nest tf /.. <br /> LF2.tI 11� 32-0-cn7 U 3� -7 <br /> J 42-OI-001 <br /> ONSITE WASTEWATER PERMIT <br /> 122102 <br />