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` ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE-3"FL-STOCKTON EA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT ``I CALL `209 953-7697 FOR INSPECTIONS XPMS 1 YEAR FRS;DATE ISSUED <br /> JOB ADDRESS 2 77 1 'f Z A Tl iP 1+4�B �Z' I CITY/ZIPS t - .n .T b_ _�1 S T <br /> CROSSSEREET �`y" APN IA2_ 1�'`� �1� �PAB•CELSUD, <br /> V­ <br /> / <br /> OWNER NAME _� P 94 ..L1 -1 ``4 5/5,C L� Ly.��1T a...v��._��.. PHONE <br /> OWNER ADDRESS L J" l'1CTrr/$� TATEIZIr i I'�. �J� -J`�y��KZI <br /> CONTRACTOR PHONE <br /> CONTRACTORADDRYET CITY/STATEJZIP <br /> LICENSE ❑CA2 ❑C-36 OTHER NDMBER E%PIMTION DATE <br /> �l WATER TABLE D£PTN: R GEOGRAPHICAL INFORMATION: Coordinller X Y <br /> �I PERCTEST N BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPUR/ADDETION ❑ ENGINEERUMMUMED/ALTERNATIVE 11 <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ IY NER <br /> NUMBER OF LIVING UNIiS: NUMBER OF BEDROOMS: NUMBEROFEMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY Sat #Of COMPARTMENTS <br /> ❑ GREASE TRAP TYPEJMFG CAPACITY SBI #OFCOMPARTMEWS <br /> r ❑ PKG TX PLANT DLSfANCETONEAREST: WELL ft FOUNDAT. fl PROPERTY LINE it <br /> ❑ LIFTSTATION See TYPEOPPUMP ❑ SAND OIL SEPARATOR(ENCWEED SYSTEM) l <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OE❑NES LENGTH OF LINES ft <br /> ` DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE It ') <br /> ❑ FILTER BED WIDTH ft LENGTH R DEPTH ft <br /> D1E'.rnNCETONEAREST WELL R FOUNDATION fl PROPERTY LINE R <br /> ❑ MOUNDED W.H. fl LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL R FOUNDATION fl PROPERTY LINE ft <br /> 6. L <br /> ❑ SUMPS Wmix fl LENGTH It DEPTH ft <br /> DISfANCETONEAREST WELL A FOUNDATION ft PROPERTYLINE R <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION fl PROPERTY LUNE ft <br /> 6. ❑ SEEPAGE PITS NUMBER WIRTH D DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION D PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> I� ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> ` MINIM UM 34 HOUR ADAANCE NOTICE REQUIRED FOR INSPECTIONS-PLESECAILI2091951-7697 <br /> SIGNED TITLE DATE <br /> 4 I <br /> I r i <br /> It <br /> T I <br /> L <br /> L <br /> O h <br /> 5 M <br /> a. P <br /> Application Accepled Bp �y.fes` q-4,- DEPAMI. SE Ll' Aro Employ-'DW <br /> Final Inspection By Data ❑ SPECIAL PERMIT-APPmvcd by <br /> ` Character of Sall la Depth NIS ED PH/Sump Soil Chamber: <br /> COMMENTS <br /> LPE SC Rete veal Chat Avocet PCrmIU n ole!p Permit IDX <br /> Colic Ingo B ash Remilbe4 ServiuR Rntp <br /> 22Z S l cS�a 3, cb iZoD yb <br /> r 42-03-001 ONSITE WASTEWATER PERMIT <br /> C rz0M <br />