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3d <br /> fry w-�NSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY LNVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 9$202-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7897 FOR INSPECTIONS ExPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS .. _ }_/�©12rN ST J2T 9g rRyAlA<,k CITY2iPA GAzn,- l YS2 A-c? ��+ <br /> p m <br /> CROSS STREET fp� TI�iP�ML_ .eo&o .,API 013--I1pp O—O5 PARCEL SIZE`' ��'>/ O <br /> OWNER NAME _ � PHONE <br /> OWNER ADDRESS r2.- z= // S7---T CTY/STATFIZIP _(Q Ogrgn—i9�Lo2O <br /> CONTRACTOR ¢ <br /> PHONE <br /> CONTRACTOR ADDRESS CITYISTATFILIP 7—u AL-O ':A <br /> LICENSE ❑C42 LC36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERM IT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION n REPAIRIADDITION ❑ ENGINEER DESIGNED IALTERHATNE <br /> D REPLACEMENT 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gel #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal 4 OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNOATION It PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> N <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION __ft PROPERTY LINE It <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It k <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It V <br /> O MOUNDED WIDTH It LENGTH ft DEPTH ft Z <br /> DISTANCE TO NEAREST WELL ft FOUNRATION ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOJNDATiON _ft PROPERTYLINE it <br /> (] DISPOSAL PONDS WIDTH ft LENGTH It DEPTH --ft1 <br /> DISTANCE TO NEAREST WEiL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SEEPAGEPITS NUMBER WIDTH ft DEPTH It { <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL HE PONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> ML40 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 4 <br /> SIGNED TITLE WN DATE <br /> I I <br /> RAII Ir An, <br /> i <br /> e <br /> VR MEN A Q <br /> 25, <br /> FE G�v <br /> 11114r- rmA in <br /> i <br /> E I <br /> 711:.1' S <br /> bEPARTMENT USE ONLY <br /> Application All Date (tet 09l'- Area Employee ID#�j�.,(a,`7-( <br /> Final Enspection Al Data ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ill Pit/Sump Sol[Character: <br /> COMMENTSy5 •� llL—D O.iZ..�6om,� 1 ' )' d- "� Sir.1li�J/ <br /> �rc1Tt��! �Yff�%Z� /2-.3'ifz cr3 �O. d S4•U�, - to � �,�� <br /> ��a _ <br /> PE SC Received Amount Date Pe Invoice Permit ID* <br /> Cada INFO ash Remitted Service R uest# <br /> lfL2Z S2l �7 .90 SS '�] <br />