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sos924� <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 301E WEBER AVE-3"Fl,-STOCNTON CA%202 -(209)465-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> N <br /> JOBADDRESSCITS'lLIP _ n <br /> CROSSSTREET K21� 1�(J APN D�1�� TY-J-03 PARCEL$12E C pG0 <br /> OWNERNAME I�lj[p�(�FGA\ 1 O�P�i� 1'15 PHONE N <br /> OWNERADDREe3 CIIYJSTATE/ZIP <br /> CONTMCTOR - e3WA I r, T-v%/- 1 1 PHONE 2001-^x4m:134S <br /> M <br /> CONTCN)RADDRE �SS xys- � yr4le Sr• CITY/STATTIZIP !']tQaAt2!4 I;s;ms- <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER ERPIMTION DATE <br /> WATER TABLE DEPTH: A GEOGRAPHICALINFORMATION: Coordinaha % Y <br /> PERCTEST(S) NUMBER Z LAND USE APPLICATIONO <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEERDMIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILLSERVE: ❑ RESIDENCE ❑ COMMERCIAL L3 OTHER <br /> NUMB ER OF LIVINGUNITSJ NUMBEROF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG_ CAPACITY 521 90FCOMPARTMENT3 6- <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal 00F COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANGETo NEARER: WELL R FOUNDATION P PROPERTY LINE fl <br /> (3 LIFTSTATION SIZE TYPEOFPUMP ❑ SAND OIL SEPARATOR(ENCLOSEDSYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS ROFLNES LENGTH OFLINES fl <br /> DISTANCETONEAREST WELL ft FOUNDATION _fl PROPERTY LINE It <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH fl <br /> DISTANCETONEAREST WELL_ ft FOUNDATION_ R PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH A LENGTH ft DEPTH ft <br /> DISTANCETONEARERP WELL__ft FOUNDATION_ R PROPERTY LINE it _ <br /> ❑ SUMPS WIDTH n LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL R FOUNDATION ft PROPERTY LME fl <br /> ❑ SEEPAGE PITS WIDTH R LENGTH ft DEPTH R <br /> DISTANCETO NEAREST WELL ft FOUNDATION R PROPERTY LINE fl <br /> 1 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 /> MINI 1 HOUR ADVANCE NOTICE gEQU1RED FOR INSPECTIONS-PLEASES CALL(209)453-0697 <br /> SIGNED TITLE_ r��etl G [P'DATE_ <br /> -T <br /> tr <br /> VWF <br /> T\ \ <br /> 7c O 354 ac <br /> ;i N <br /> 5M q <br /> DEPARTMENT USF ONL <br /> Application A epted 5 ` to V Are. Empi"IM <br /> FIA.I In.pedio By- Date ❑ SPECIAL PERMIT-Appmved by 9 <br /> Chvncterof$oll haf3 Pivsump Soil C�hh.1.0er: <br /> COMMENPSoC <br /> PESC Reoelvtd ChecWl! Annust Date PermiU Involce0 PerMtIDO <br /> Cade INFO B . Remllttd Servi..R .mtB <br />