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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENWRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCNTON CA 95202-(209)6683620 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB AGDRESS I 570 W E'I&HT MJLe R-A cmzP 970UL7�r (H <br /> ! 4k5) C. <br /> CROSS STREET (VEIJI CE ISL-ANIS) APN 00-040-OLP PARCILS¢E 1506 A' <br /> e <br /> OWNER NAME 2ECLAn1A-n DM D1 iT. 2023 PHONE IDO3 -srla-+ <br /> DWNERADDREss JD1•I-AI MEED T (440 ARUNDEL Cy-- cmytsu zP L.DDI,CA 9C?-q-4 <br /> coNmAGTOR_ L11IE OI^A•1.1< [�OE� jIZoNME�/tL PHONE 3&y-1037-5- <br /> CONRGCTORAOT <br /> DRESS /T W• CAA— JT- CRYISTAT1ZIP Lm(71 CA q/ 7- C <br /> LICENSE QC42 QC36 GTHER NUMBER <br /> EDPIMTON DATE <br /> WATER TABLE DEPrH: R GEOGRMPHICALINFORMATON: COOrrlin8h5 X Y <br /> PERC TEST #--,L— BUILDINGPERMR# LAND USE APPLICATION# <br /> TYPE DF WORK: ❑ NMINSTALLATON 0 REPAIRIAaOmON ❑ ENGINEERDESIGNEDIALTERNKTIVE <br /> 0 REMACEMENT 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL 0 OTHER <br /> NUMBER OF WNG UHTT3: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPFJMFG CAPACT 981 #OFCOMPARTMENTS <br /> ❑ GREASETRAP TPFJMFG CAPACITY 981 #OFCOMPARTMENTS <br /> DISTANCETONEAREST WELL it FWNWTION R PROPERTY LINE ft <br /> ❑ LIFTSTATION SUE TYPE OF PUMP O PKGTXPLANT ❑ SANDOILSEPARATOR(ENCLOSEDSYSTEM1O <br /> ❑ LEACH LINES ❑ LEACHINGCHAMBERS #OFLINES LENGTHOFLINES R <br /> DISTANCETO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ FlLTER BED WIDnI ft LENGTH R DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTYLINE it <br /> ❑ MOUNDED YNOTN it LENGTH - it DEFm it <br /> DISTANCETONEAREST WELL it FOUNDATON ft PROPERTY LINE it <br /> ❑ SUMPS Wmm it LENGTH ft DEPTH R <br /> DISTANCEMNEAREST WELL it FOUNDATION it PROPERTY LINE If <br /> ❑ DISPOSAL PONDS WIDTH it LENGTH it DEFm ft <br /> DISTANCE TO NEAREST WELL it FOUNGATION R PROPERTY LINE R <br /> ❑- SEEPAGE PITS NUMBER PAom ft DEPTH If <br /> DMTANCE TO NEAREST WELLit FOUNDATION it PROPERTYUNE R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORGANCE INTTH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> �INIMlJM26110UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ������ TITLE CONSUC!]CiNr DATE S 110 <br /> Z <br /> W <br /> Lu o C F <br /> N uzm <br /> ZL4 <br /> U LLI o Sow <br /> W a- O>rz <br /> CC ¢ 'Lz¢ <br /> a uJ <br /> w z <br /> /p� DEPARTMENT BE LY J,,� <br /> ApPlieafien Aec.Pted BY Data 4 •� Area �. Employee ID#_I s LAk'+ — <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 FD PiMump Soil Character: <br /> COMMENTS <br /> PE SC Received Ch"W Amount PermiU <br /> Cade INFO B Cash Remktetl, Date Servtu Re uest# Inwice# PermRID# <br /> 1 D" '421(9 '716C)7H603 <br /> -0I ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 10MATT <br />