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L L� ONSITE WASTEWATER TREATMENT SYSTEM PERmfiCANNE® <br /> SA OAQUINCOUM ENVIRONMEM'ALHEALTHDEPARTMEM' 304E WEBER AVE 3'FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 1_0� ^l -, F9e Tleec CITY/,+Z-IFP .-A4-t•J <br /> f5 a <br /> I CROSS STREET [F r� '-94147 * APN �.tY�gl /7 PARCELSIZE <br /> L T 2 J <br /> OWNER NAME Q <br /> �PHONE <br /> OWNERADDRESS ?5Rwo Lo"r- CITYISTATrITP 65Ec,_A4�//`9_ JS('4�•/-/75�5,yn <br /> . <br /> LCONTRACTOR a& -5 clo- C­ PHONE (,o(o1-C2-1 <br /> CONTRACTORADDRESSF 51oz t ,Aa,*e L).S A CIMSTATIZ., CA . 9-534(o <br /> LICENSE 0 C4 L3 C-36 DTHER NUMBER 57(00uEKPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICALINFORMATION: CoordilmteT X Y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: )L NEWINSTALLATION ❑ REPA,WADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE t <br /> ❑ REPLACEMENT ❑ DESTRUCTION tttVvvv <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> ,q NUMBER OF LIVING UNITS: $ �T� NUMBER OF BEDROOMS: I _� NUMBER OF EMPLOYEES: �Y <br /> pL SEPTIC TANK TYPFIMFG 5wcn,6 ���� CAPACITY �� _Rel #OFCOMPARTMENTS fX <br /> L ❑ GREASE TRAP TYPEIMFG nn ` CAPACITY gal #OF COMPARTMENTS <br /> L ❑ PKG TX PLANT DuDANCETONEARRSr: WELL V R FOUNDATION R PROPERTY LINE it <br /> ❑yy <br /> LIFT STATION SIEE TYPEOPPUMP, ❑ BAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> K LEACH LINES ❑ LEACHING CHAMBERS #OFLINES Z LENGTH OF LINES Ino � ft <br /> DISTANCLTONEAREST WELL W f� ft FOUNDATION Irj R PROPERTY LINE _y A <br /> ❑ FILTER BED WIDTH A LENGTH R DEPTH fl <br /> 1 DuTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH A LENGTH 0 DEPTH ft <br /> ` DISTANCETONEAREST WELL R FOUNDATION R PROPERTY LINE fl <br /> ❑ SUMPS WIDTH R LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE IT <br /> ❑ DISPOSAL PONDS WmTH R LENGTH ft DEPTH It <br /> Be, D,kTaNCETO NEAREST WELL R FOUNDATION B PROPERTY LINE R <br /> KL SEEPAGE PITS WI/* 421' R LENGTH ft DEPTH '251 ft <br /> DISTANCE TO NEAREST WELL-4';—ft FOUNDATON R PROPERTY LINE ft <br /> Bar I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> L HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIIO/NS-PLEASE CALL(209)953-7691 <br /> SIGNED /+ TITLE (/-/r- DATE <br /> UP <br /> � I <br /> 7 Iv D IT- <br /> be. <br /> E0 4 J A L <br /> AAU <br /> + DEPARTME USE NLY <br /> Application Accepted B — Date Area Employee ID# <br /> ppro [1/¢l <br /> Final Inspection By Dale ❑ SPECIALPERMIT-Aved by <br /> y Chancterof Soil to De ot3 FV PiVSump II Character: <br /> COMMENTS _ !'— — A/ <br /> FBL icy-sy�d�'J7 i2e�: <br /> ri i' �!%dct3 c <br /> PE SC ReaelYed C eek# Amomt Permiu <br /> Cede INFD B ae Remitted Date Se'I.Request% Involceq PermitlDk <br /> f rL o y <br /> Sea <br /> 42-! m <br />