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tbim <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 88202-(209)488-7420 <br /> NON-REFUNDL CALL 209)953-7 7 R INSPECTIO ExPRFj 1 YEA AT SUED <br /> JOB ADDRESS CITY21P ' / <br /> 1 <br /> CROSS STREET L '`�N' 1 '� PARCELSIM <br /> OWNER NAME N PHONE �' <br /> OWNER ADDRESS CITYISTAT P ` F <br /> 14 �OIQS <br /> CONTRACTOR •.f J ' 'I F, � � � }/�� � PHONE O / <br /> CONTRACTOR ADDRESS L� \�-r – !l CITYISTATEMP <br /> LICENSE XC42 QCJS OME0. A NUMBER IW51 1 E%PIRATIONDATE �I <br /> WATFJI TABLE DEM: fl GEMMPHIOALMFORWTNXY: Coordinates X Y <br /> fJ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I I NEW INSTALLATION r REPANVADDITKW ❑ ENmNEER DESIGNED(ALTERNATIVE <br /> 11 REPLAOEMEM 11 OUT-OF-SERVICESEPTWSYBTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE x COMMEscuu. <br /> O <br /> NUMBEROFLMNOUNn: NUMBEROBEDRM$: Nu= <br /> OF EMOYEES: <br /> SEPTICTANK TYPE/MFGFVLJTW l7 fj <br /> CAPACITY gal #OF COMPARTMENTS <br /> O GREASETRAP TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> DISTANCE TO NEAREST: WELL R FOUNDATION R PROPERTY LINE ft <br /> O LIFT STATION S1ZE TYPE OF PUMP D PKGTXPLANT 0 SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> O LEACH LINES ❑ LEACHING CHAMBERS #OFLINES LENGTHOFUNES ft <br /> DISTANCE TO NEAREAT WELL R FOUNDA1104 R PROPERTY LINE ft <br /> FILTER BED MOTH k 7 R L UE-ft— <br /> DEPTH 7 ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION JCXY R PROPERTY LINE If <br /> O MOUNDED MOTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION fl PROPERTY LINE it <br /> O SUMPS WIDTH R LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> O DISPOSAL PONDS WIDTH fl LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTYLINE It <br /> O SEEPAGE PITS NUMBER WIDTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION it PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> pp��. STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNEQMVD IA24 H�URIpDNANGFAlOI5I REQUIRED POREN13�f �6+TIONS{PEA <br /> ISE CALL A20E9)953 -7697 <br /> kill <br /> "s SEP 0 6'2 <br /> 1 AN <br /> A•_ J T` <br /> Min mn <br /> Lr <br /> ISI T� xeLA>Em _ 11 .p"P � <br /> Application Accep Date _ Area Employee ID# 7 <br /> Final Inspection -� —11 '44 oat e � // ❑ SPECIAL PERMIT_Approved by <br /> Character of Sol l toplh off 7 PCPi r <br /> ump Soil Chaactor: <br /> / <br /> COMMENTS !4/r! .� ' /"�/C>E 1 i,. .Y�'!i Tg,' <br /> pr f !�• CX.I fes/ _ x+�7i SYi�' n/c _.__ —__. — <br /> PE SC Recelvetl Che Amount Dab Permit/ Invoice# Permit IDD <br /> Cade INFO B h Remitted Service Ra ue$t# <br /> 2 �/L{� 2 3 <br /> 42-01 1500 + 12.030 = 2760x . `�O ���� NSWASTMATERTRTMNT SYSTEM PERMIT <br /> BM110 <br />