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use^ z3o <br /> 3 ONSITE WASTEWATER TREA-rivi NT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-RPFUNDABLE PERMIT CHILL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /�/ /� _ __ <br /> __-____CITY21P,_ -C�6�PAR�CE�LSCROSS STREETAPN I! 'IZLF;M#III,q <br /> OWNER NAME(!511 �A Jy <br /> PHONE 9<--r z <br /> OWNER ADDRESS)?&&_ __ .�L.`t•_-_- ___.....__,. _ CITY/STATE/ZIP <br /> CONTRACTORPHONE <br /> CONTRACTOR A0 <br /> SS ^^ �J'f, _^ ..._. .__-__......... ....CITYISTATEMP���%-�'_ly`�Y`«�- <br /> LICENSE 0- C-42 I 1 C-36 OTHER -_ - NUMBER j,S�Z+/._/4!. .EXPIRATION DATE <br /> WATER TABLE DEPTH:--2( it GEOGRAPHICAL INFORMATION: Coordinates X _ ._ .- Y_ <br /> Ci PERC TEST #_-_.- _ BUILDING PERMIT# — LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT _ OUT-0F-SERVICE SEPTIC SYSTEM DESTRUCTION �J <br /> INSTALLATION WILL SERVE: C RESIDENCE COMMERCIAL !1 OTHER <br /> NUMBER OF LIVING UNITS:- NUMBER OF BEDHOOMS: ._ _ NUMBER OF EMPLOYEES: ! _ <br /> SEPTICTANK TYPE/MrG __-.. CAPACITY �_ 7(� gal HOF COMPARTMENTS_,_ <br /> ❑ GREASETRAP TYPE/MrGCAPACITYgal H OF COMPARTMENTS.. _ <br /> DISTANCE TO NEAREST: WELL __. LC. -l" 11 Fot INDAII0N_._ 1I PROPERTY LINE r/T11 ft <br /> ❑ LIFT STATION SIZE _ ._.__TYPE OF PUMP.. ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBERS _ ._ _ II I A LINES � LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL:>C-�-�"----`' _ it FOLIfJI 4l ION _ Qt h PROPERTY LINE Ta ft <br /> ❑ FILTERBED WIDTH _ - - It LENGTH_ -_ ft Du,IH_ — it <br /> DISTANCE TO NEAREST WELL---- it FOUNDATION_- _.. ------it PROPERTY LINE.—. .it <br /> ❑ MOUNDED WIDTH ____- -._it LENGTH -_-__ __ -- ft DEPTH it <br /> DISTANCE TO NEAREST WELL It FOUNDATION it PROPERTY LINE it <br /> �-SUMPS �i WIDTH _—'L __it LENGTH _ it DEPTH�. )�i1 <br /> DISTANCE TO NEAREST WELL. It FOUNDATION f�—it PROPERTY LINE,' 7" It. <br /> ❑ DISPOSALPONDS WIDTH ____.. ----___-_-.—Ft DEPTH _. .___..----_-._.it <br /> - _ ff LENGTH ,---._.._._ . <br /> DISTANCE TO NEAREST WELL______ 11 1OLINDATION h PROPERTY LINE--__-.-__ It <br /> ❑ SEEPAGE PITS NUMBER—-_- - __ WIDTH _...__. __.--_ _.--,it DEPT I _-__h <br /> DISTANCE TO NEAREST WELL__-_-__ it K)UNDAIK.MI-__.-___--__h PROPERTY LINE _-.it <br /> 1 I IEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WI fit SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOU,ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 l <br /> SIGNED_ 1.-mss/' - --------- - TITLE G - _- DATE.��_ 2 i f <br /> Ar <br /> / Iced <br /> - I - - — - <br /> EpART�41t NT 11SE_ciNLY <br /> Applic ion Acce Date �J _f I r Area .�C\� .. Employee ID#. i, vff0 <br /> --- 3 <br /> Final Inspection By-P'��7v <br /> — Dale- L_ .l�.—_ SPECIAL PERMIT-Approved by_ <br /> Character of Soil to Ft: —_—_ __—. PH/Sitnip Soil Character: <br /> COMMENTS <br /> --!a:' <i• <br /> PE SC Received Check#/ Amount Date PermiU Invoice# Permit ID# <br /> Code INFO I BV Cash r RemHted Se/r�viice>Re uest# <br /> 1-7 t.!! T- L7 SPUD -- <br /> 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4124112 <br />