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�w <br /> ONSITE WASTEWATER TREATMEYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDARLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> 7 <br /> { APN r _ If-2-5-0 <br /> JOB ADDRESS 9 <br /> /J 'O ' 2-�0•- 017PARCEL SIZF. ILI,. - <br /> CROSS STREET _ l.'/r'r(��j �* � <br />' ON'N EA NAM£ Ci' !F![I M /PHONE _ <br /> Y��3 <br /> L <br /> -7 CITY/STATE/ZIP <br /> OWNER ADDRESS � <br /> CONTRACTOR Valle ialle/-,( � C PHONE 3�'> r� <br /> CONTRACTOR ADDRESS '7[Y*7 C> t .Ss-J'i' Y — CITYISTATFJZ1P 4",/, <br /> ` LICENSE C-42 ❑C-36 OTHER - y.S NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: fl GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) NUMBER LAND 11SE APPLICATION# <br /> 1 TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNEDIALTERNATIVE <br /> LlREPLACEMENT DESTRUCr[ON <br /> t' <br /> INSTALLATION WILL SERVE: "RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> J ! of <br /> f Jt IM <br /> SEPTIC TANK TVPEMFa CAPACITY /,-,b — <br /> gal #OF COMPARTMENTS <br /> �-- L) GREASE TRAP TYPE/MFGCAPACITY gal #OF COMPARTMENTS <br /> y7 i <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL --�_ R FOUNDATION �� fl PROPERTY LINE lav it <br /> ❑ LIFT STATION SIzE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LILEACHING CHAMBERS _ #of LINE677 yn ft LENGTH of LINES _ <br /> ' PO R <br /> DISTANCE TO NEAREST WELL- 7L ft FOUNDATION �_I R PROPERTY LINE _ <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH ft <br /> I :I DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPBRIY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH R DEPTH ft <br /> D[STANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH fl LENGTH ft DEPTH ft <br /> d DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> }meq DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br />' } ' SEEPAGE PITS(Z�YIOTH ,3 r ft LENGTH - ft DEPTH 2 5� , ft <br /> Fl DISTANCE TO NEAREST WELL //S ft FOUNDATION „_ft PROPERTY LINE �]S B <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY Oki)INANCES, <br />+ STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQU IN COUNTY. <br /> MUM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 4204)953-7697 �r'f <br /> I" SIGNED TITLE_�.z l r/ /r _ DATE l /--c,A/ <br /> W <br /> t t " <br /> qq <br /> 1 <br /> 3 .1 <br />' WSJ H <br /> 47H <br /> I,% t--' L <br /> tr <br /> DEPARTMEN LSE NI.Y S,3 L� q/qci <br /> IV Application Aecep4 - Date l -G Area <br /> E <br /> mployee ID# _li <br /> [_ Final Inspectio By Date ❑ SPECIAL P MIT-Approved 6y <br /> Character of So o Depth 3 Ft; Pit1sump Soil Character: <br /> COMMENTS 0 I rt lot J <br /> 011 a may , <br /> PE SC Received CAmount Data Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> Sao � � �� <br /> 42-01-061 ONSITE WASTEWATER PERMIT <br /> ar._ <br />