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<b <br /> t ONSITE WASTEWATER TREATMh ' SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE--1-FL-STOCKTON CA 95202 - (209)465-3420 <br /> -NON-REFUNDAB]LE/PERMIT f CALL(209)953-7697 FOR INSPECTION'S EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 1�y�yL�o�� Sf �T � CITY/ZIP <br /> J F �} <br /> II } CROSSSTREET �;i/,d- 1���� � A P N C,�� '"��C)"7"I G` PARCEL SIZE V <br /> OWNER NAME � le <br /> k _ /� JG ![?2j - .,- PHONE <br /> PkPk OWNER ADDRESS �ff YJJ©"1 CITY75TATE/ZIP <br /> �f ep��fjams <br /> 95a�-7 <br /> CONTRACTOR ze-1/ / 416� 1PHONE <br /> CONTRACTOR ADDRESS �vh <br /> -4l.7/..n'/CS/ '�*:r/C_ CITYISTATEIZIP <br /> �j LICENSE N(C-42 iJ C-36 OTHER NUMBER EXPIRATION DATE6�r <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) NUMBER LANE)USE APPLICATION# <br /> TYPE OF WORK: C9, NEWINSTALLATION LI REPAIR/ADDITION D ENGINEER DESIGNED/ALTERNATIVE <br /> d REPLACEMENT CI DESTRUCTION <br /> L INSTALLATION WILL SERVE: ij RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: 3 NUMBEROFEMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY 16W gal #Of COMPARTMENTS <br /> I ♦ ❑ CREASE TRAP TYPE/MFG CAPACITY gal #-OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL la2lg— . R FOUNDATION S ft PROPERTY LINE <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> c - LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES Il <br /> DISTANCE TO NEAREST WELL�S-G�- ft FOUNDATION ,[�� ft PROPERTY LINE 5 fl <br /> rkf�-� ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> ! DISTANCE TO NEAREST WELL 11 FOUNDATION fl PROPERTY LINE It <br /> I ❑ MOUNDED WIDTH ft LENGTH ft DFPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEATH n <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTR ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE 2 <br /> 'moi• �- SEEPAGE PITS WIDTH _ 3` ft LENGTH ft DEPTH 9:2: ft <br /> ' DISTANCE TO NEAREST WELL lSbr ft FOUNDATION.,_,-,."�-__ft PROPERTY LINE �� ft <br /> E 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. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 1209)953-7697 <br /> SIGNED TITLE 'Y7� /> - PAT$ <br /> L <br /> "Y <br /> 1 n <br /> o . <br /> N <br /> li <br /> L <br /> F1 l <br /> j PL1 UG t � tiH Q!VI'I <br /> P t DEPA T I15.ON Y },I,qj <br /> Application Accepted By <br /> Date Area Employee[DO <br /> -'f <br />! FLnal Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character ofSoil to Depl 013 Ft: n Pit/Sump Soil Character: <br />[ COMMENTS e_s e[ d1 ¢ � ./ fT��� j �n�zL 3 <br /> 1 � <br /> PE SC Received Chec #I Amount Dale Permill Invoice# PermitID# <br /> Code NFO By as Remitted Service Request# <br /> 41 �-� q �1�03 <br /> 42-01-001 <br /> ONSITE WASTEWATER PERMIT <br />