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�w <br /> v�. ONSITE WASTEWATER TREATMET. -)SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3 FL-STOCKTON CA 95202 -(209)468-3420 <br /> 1 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> w CITYIZIP LCT -7 .. <br /> JOB ADDRESS 1 71, t 0 H • <br /> , �� M <br /> CROSS STREET Lf Cz APN "OSI-2�U^ O/ PARCEL SIZE�f IV <br /> � <br /> �i <br /> OWNERNAME �((}}+ruL/It {� JPHONE �d 777 Yn� <br /> OWNERADDRESS PC/ r 'r,R ✓ CITYISTATE/ZIP <br /> CONTRACTOR 4I y r:lll C PHONE <br /> CONTRACTOR ADDRESS! 7inc)0 C r - 1 � /�l. CITYISTATE/ZIP G"A/ <br /> LICENSE C-42 ❑C-36 OTHER C �,jr NUMBER EXPIRATION DATE <br /> -.— WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT DESTRUCTION <br /> 1 NSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYP£/MFG l iy6th 1'e-ad (— CAPACITY /--)Oo gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACrrY gal #OF COMPARTMENTS <br /> 7 <br /> ❑ PKG TX PLANT DISTANCETO NEAREST: WELL U I ft FOUNDATION /S ft PROPERTY LINE 100 fl <br /> Fit ❑ LIFT STATION SIZE TYPEOFPUMP LlSAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS N OF LINES B LENGTH OF LINES <br /> � DISTANCE TO NEAREST WELL F, 7e). R FOUNDATION 7i1 R PROPERTY LINE <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH R <br /> _ DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> y^ ❑ MOUNDED WIDTH fl LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> �i ❑ SUMPS WIDTH ft LENGTH R DEPTH H <br /> i DISTANCE TD NEAREST WELL Il FOUNDATION ft PROPERTY LINE fl <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH - fl DEPTH ft <br /> e� DISTANCE TO NEAREST WELL fl FOUNDATION ft PROPERTY LINE ft <br /> f SEEPAGE PITS(0w..Tx - ft LENGTH - R DEPTH --;)S ' ft <br /> j /, DISTANCE TO NEAREST WELL //.� ft FOUNDATIONY'nfl PROPERTY LINE '7.7 ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE1N ACCORDANCE W ITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. - <br /> MUM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- <br /> `/PLEASE CALL(2091953-7697 / /`� <br /> SIGNED TITLE_�rt f/Ilf�f DATE ! a7 <br /> . J <br /> AM <br /> 1 <br /> �i <br /> t <br /> �lN <br /> 0 <br /> DEPARTMENT USE NLY <br /> Application Aecep - .y Date 1 ?-� 1 Area 2f L Employee ID# "1 <br /> 1 VPI Final Inspectio By Date ❑ SPECIAL P MIT-Approved by <br /> Character of So o Depth f 3 Ft: PiGSump Soil Character: <br /> COMMENTS 01cL 1aj +l�•�'c_c� ale <br /> a '` <br /> PE SC Received C Amount Date Permit/ invoice Permit lD# <br /> Code INFO 8 Cash Remitted Service Re ucat# <br /> F. fat) ti C7 (d. <br /> L42-01-001 _ _ - - ONSITE WASTEWATER PERMIT <br />