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f ' <br /> t ONSITE WAST WATER TREATMENT SYSTiw I PERMIT' <br /> • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEI-.RTMENT 304 E WEBER A► 3"FL-STOCKTON CA 95202 (209)468-3420 <br /> I NON-REFUNDABLE PERMIT ' CALL(209)-953-7697 FOR INSPECTIONS <br /> EXPIRES I YEAR FROM DATE.ISSUED <br /> JOB ADDRESS / 0 <br /> CITVIZIP J �( <br /> }CROSS �� �STREET . � 2 Ca, � APN 4drO Y 1 )� PARCEL SIZE I O• �F 70y <br /> OWNER NAME N PHONES Oy <br /> OWNER ADDIIESS - CITYISTATEIZIP �'''�" 7 <br /> CONTRACTOR PHONE !J�49elIZI <br /> CONTRACI'ORADDRESS I—,-? -�7 l.!/� n7 CITYISTATEIZIP <br /> LICENSE )aC42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: . Coordinates X Y <br /> 0 PERC TEST(S) NUMBER LAND USE APPLICATION# .; <br /> TYPE OF WORK: 7_ NEW INSTALLATION ❑ REPAiRIADDITION ❑ ENGINEER DESIGNED IALTERNATIVE <br /> REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATIONIVILL,SERVE. ❑.RESIDENCE. „COMMERCIAL ©, OTHER <br /> .NUMBER OF LlVliy( UNITS NUMBER OF BEDRQOMS: •, NUMBER'OF,EMPLOYEES: ' <br /> ❑ SEPTIC TANK TYPE/MFG 3 r `r CAPACITY 7-`' �-ow <br /> gal #OF COMPARTMENTS <br /> ❑ CREASE TRAP TYPE/NIFG ` ''CAPACITY gal #OF COMPARTMENTS <br /> f ❑ IPKG TX PLANT .'DISTANCE,TO NEAREST -WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ LrIFTSTATION; SIZE TYPE OF Pump ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES Sr LENGTH OF LINES „, 5�n ft % <br /> +DISTANCE TO NEAREST WELL �� t 'FOUNDATION _ft _ PROPERTY LINE _ ,ft, <br /> ❑ FILTER BED WIDTH ft LENGTH R DEPTH f:` <br /> DISTANCETO`NEAREST WELD ft FOUNDATION ft PROPERTYLINE R <br /> ❑ MOUNDED- WiDTH ft LENGTH ft DEPTH ft4 <br /> DiSTANCE.TO:fNEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> P s <br /> '-SUMPS WIDTH ft LENGTH ft, . DEPTH ft. Z <br /> DISTANCE TO'NEAR$'.,. <br /> ST WELL :t <br /> �ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft L$NGTH ft DEPTH ft <br /> DISTANCE TD NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> y SEEPAGE PITS WIDTH ft - LENGTH ft DEPTH 'iZ,.Syf tt <br /> l ` <br /> l <br /> ft FOUNDATIONDISTAN E TO NEAREST WELL 1 <br /> fl PROPERTY LINE rft <br /> I,HEREBY CERTIFY THAT I'HAVE PREPARED THIS APPLICATION AND THE WORK WILLBE DON&IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,A <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN�COUNTY. <br /> M MUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNE TITLE <br /> DATE <br /> -» <br /> c/ <br /> t <br /> •�; .. <br /> 4' <br /> E ! {{ <br /> 112"t <br /> 1 ._,J - <br /> n. <br /> f !2Jy <br /> d HF LFN 5fR CE <br /> a'E VIFt NM.N <br /> a ptP RTMENT Ul - NII:Y--— <br /> Applieation Accepted$ Date- '3 3 Area Employee ID# <br /> Final Inspection" ale T`{�j' "'" `SI:C7A) 121y71 i" Approves)by <br /> Character of Soil to De of 3 Ft: " Pit/Sumo it Character: <br /> COMMENTS SA of 77 <br /> --- a <br /> ILE�65yCY <br /> 1-11 r <br /> PE Sc Received Check#/ Amount Date PermiU` Invoice# Permit 1D# <br /> INFO .. B as Remitted Service Request# <br /> 2 -7(.q 350 033 2q 3 <br /> ATER• <br /> i xJ <br />