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�y G'qq��v�(�1S A�2rALS <br /> ONSITE WASTE"'ATER TREATMENT SYSTV4 PERMI <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAW04ENT 304 E WEBER A V E„ ,j FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> /A <br /> JOB ADDRESS L A/1 � <br /> 22P-7 — �/��7./ /tlp CITY/ZIP ry <br /> CROSSSTREETL�r� Wry l/ APN rr0 —o•3�-1U PARCF.LSIZE .2Y17 D <br /> OWNER NAME GALA-V-�f—� S yT•�Tz Ir�LS� �N�, PHONE n <br /> O"ERADDRESS r CITY/STATE/ZIP <br /> CONTRACTOR nfJAI <br /> ICUL�;C �r��G •I r / •� PHONE/Vr r <br /> CONTRACI'ORADDRESS .v/[1�� IJr7_1T_ yIJZ `E / CITY/STATE/ZIP /STZ-'rJ ,2Q- <br /> LICENSE ❑C42 ❑C-36 OTHER C-5 NUMBER •�P EXPIRATION DATE O <br /> WATER TABLE DEPTH; R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> . PERC TEST(S) NIIMBF.R LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH ft n <br /> DISTANCF.TO NEAREST WELL H FOUNDATION 11 PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH Il LENGTH It UEPIII <br /> DISTANCE TO NEAREST WELL It FOUNDATION 11 PROPERTY LINE ft 1 <br /> ❑ SUMPS WIDTH It LENGTH H DEPTH R •l-�f- <br /> ]DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH R DEPTH_ Il <br /> DISTANCE TO NEAREST WELL D FOUNDATION It PROPERTY LINE It <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH B DEPTH n (� <br /> 1y DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> 1 HEREBY CERTI ATI NAVE P . RED THIS APPLICATION AND THE WORK WILL BF.DONE IN ACCORDANCE:WITH SAN JOAQUIN COUNTY ORDINANCES. i1 <br /> S” IT:LA S AND RULES AND REGULATIONS 01:SAN JOAQUIN(-UN'I'T, r <br /> @� ,t _L&IIN M 2 UR ANCE NOTICE REQUIRED FOR INS�PSECT�IO,NSS--PLEASE CALL(209)953-7697 #, <br /> -SIGNED TITLE �l/`fT�TJJ GrrYt-(ZDATE. 1*x�I <br /> l <br /> h I t <br /> .hr tii IJJI. L <br /> W <br /> 414 1 <br /> O I <br /> s <br /> € „ <br /> . N <br /> - <br /> IT -Ih FIT <br /> /7�t1/7 DEPARTMEN US ONLY <br /> Application Accepted B Date _j/ 1 3 f) Area �2_1 Employee ID# <br /> Final Inspection By �P�e" Date ❑ SPECIAL PERMIT-Approved by <br /> CM1aracter of Soil to pt -hJf Pit1Sump Soil Character: <br /> COMMENTS ��16/L��1/I u � � / l S g / I <br /> PESC Received eck#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code I'm B Remitted Service R uest It <br /> 2-22- 5-21 y1 �3 GU 7 13 D -R <br /> 42-01-001 ONSITE WASTEWATER PERMIT <br /> 12rZ02 <br />