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f( !QNSITE WASTEWATER TREATMENT SYSTEM PERMIT /J3� <br /> SAN JOAQUIN COUNTY~HVIRONMENTAL HD <br /> 1 EALTHEPARTMENT 606 E MAIN STREET-STOCK70N CA 95202-(209)46tt-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7$97 FOR INSPECTIONS EXPIRE$1 YEAR FROM DATE ISSUED <br /> t JOB ADDREss 2-1 d p CITYILP e&Zao SZ m <br /> CROSS STREET -T.[e_.,�('�.�- APN L!/ PARCEL SIZE _3 Sy o <br /> OWNER NAME aff�/ ZL{/V'oye PHONE m <br /> OWNER ADDRESS -T-oer, CITYISTATEIZIP 464,162 9SL LU <br /> CONTRACTOR / PHONE <br /> CONTRACTOR ADDRESS -- __•p CO ` 1�(p <br /> ��. CITYISTATEiZIP�tL2 LOr-(e- �Sr3PI <br /> I � <br /> LICENSE 71C-42 ❑C-35 OTHER <br /> �7 NUMBER -EXPIRATION DATE <br /> WATER TABLE DEPTH: f 6- ft GEOGRAPHICAL INFORMATION: Coordinates X y <br /> PERC TEST #W BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIAODITION ❑ ENGINEER DESIGNED IALTERNAnve <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOM$: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> 0 GREASE TRAP TYPEIMFG CAPACITY gal #OFCOMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #oFLINES LENGTH OF LINES ry N <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE (( <br /> ❑ FILTER BED WIDTH ft LENGTH ry DEPTH It <br /> DISTANCE TD NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> O MOUNDED WIDTH ft LENGTH ft DEPTH ft � I <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE tt <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft P14OPERTYLINE ft <br /> f3 DISPOSALPONDS WIDTH ft LENGTH ft DEPTH <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ SEEPAGEPITS NUMBER WIDTH It DEPTH ft i <br /> DISTANCE TO NEAREST WELL _ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS•PLEASE CALL(209)953-7697 �{� <br /> SIGNED v r ` TITLE D�� DATE�.J <br /> -0g <br /> I <br /> i <br /> V R M tJ A Q <br /> i <br /> S <br /> ci44 1< <br /> TET <br /> Application Acce Data T 09" Area Employee ID# <br /> Final inspection Date ❑ SPECIAL PERMIT-Approved by <br /> Character Of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS H CCPD " l, IZ. L0�+9�i�i1' � �•�F� '�G.2•Sdr.J.i�) <br /> PE SC Received eC Amount Date perm t! Invoice# Permit ID# <br /> Code INFO B ash Remitted Service R Uest# <br /> �Fa2z sz f IDO 5S <br />