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(D <br /> 3=3 <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE-3-FL-STOCKTON CA 95202 -(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS E PIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESE CITYJZIP !1 j <br /> CHOSE STREET l APP AT-7- /- 01 <br /> PARCELLSIZE <br /> OWNER NAME / 'J A-z- /G L PHONE (O — . <br /> OWNERADDRE3E '/I� �G/N l)G� /`l N� CITY/STATFJZIP ?rlo <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATVZu, <br /> LICENSE (3 C-42 L)C-36 OTHER NUMBER EXPIRATION DATE <br /> WATERTABLEDEPTH: R GEOGWHICALINFORMATION: Coodloates X Y <br /> ❑ PERCTEST p I BUILDING PERMIT LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEWINSTALLATION ❑ REPAIR/ADDITI ❑ ENGINEERDESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT DESrRUCOON <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NDMBEROP WVINO UNRS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY IPI #OFCOMPARTMEMS <br /> ❑ GREASETRAP TYPE/MFG CAPACITY Set p OF COMPARTMENTS <br /> ❑ PKG TX PLANT DLSTANCETONEAREST: WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ LIFTSTATION SIZE TYPEOFPuMP ❑ SAND OIL SEPARATOR(ENCLOSEDSYRISM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS NOFLINEE LENGTHOFLINES ft fj <br /> DiWANCETONEARESI' WELL R FOUNDATION R PROPERTY LINE R V� <br /> ❑ FILTER BED WIDTH R LENGTH R DEPTH R w <br /> DIBTANCETONEAREET WELL R FOUNDATION R PROPERTY LINE R V) <br /> ❑ MOUNDED WIDTH R LENGTH R DEPTH R <br /> DISTANCETONEAREST WELL R FOUNDATION R PROPERTY LME R y- <br /> ❑ SUMPS WIDTH R LENOTH R DEPTH R <br /> 1 DLSTANCETONEARM WELL ft FOUNDATION R PROPERTY LINE ft (11 <br /> Cl DISPOSAL PONDS WIDTH ft LENGTH R DEPTH it <br /> DISTANCETONEARERr WELL R FOUNDATION R PROPERTY LINE it W <br /> ❑ SEEPAGE PITS NUMBER WIDTH it DEPTH, it A <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R �J <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY I` <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. dX <br /> MINIMUM 34 H0 DVANCE NOTICE REQUIRED FOR INSPECT IONS-PLEASE CALL.QNI 953-7697 <br /> SIGNED TITLE .O/yA liY DATE If;7.7 <br /> d <br /> 1 <br /> P <br /> DEPARTMENT SW E OyLV - :�k72 <br /> - ApplbMbn Accepted By. _ _ __ Deb 11,2--710 L.__.Are _-...._ Empbya-ID# t - <br /> FlnMlospedbnBy Data 8,11.2 g6 ❑ SPECIAL PERMIT-Appmvd by <br /> Character of Soil ro Depth of 3 FF- PR/Sump Solt Character: <br /> COMMENTS No A4(eke c-,,,;=.0 /11r-C $:hWAM <br /> �..J-4.f I.RY.—yc16 II, A 1 4A_ <br /> C/ <br /> PE SC Received hec Amount b Permltl Iavoke0 Permit ID# <br /> Cade IRFU Bab Remitted Servitt untN <br />