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I� <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 171949,9 SOuTN COrrN ONE X Rn CITY/ZIP M,Q A/17FC el 9 <br /> CROSS STREET SPATE. HW� /ZO APN 2019-18D-Z3 PARCEL SIZE G.42 Ac <br /> OWNER NAME STANLEY VANDEQ VkF..AI PHONE ff 71, <br /> OWNERADDRESS SIS F/�S'f ST- CITYISTATEMP FSC.ALON�(•A 95320 _ <br /> CONTRACTOR PROVOST e PR/TCNA2L) C0N1u<T/N4 6eCk" PHONE 2-0f4, -IasZ <br /> CONTRACTOR ADDRESS 470/ S/fK R0 / CITYISTATEMP /Y7Op6STO,CA 'ySJTG <br /> LICENSE UC-42 1C-36 OTHER R CE NUMBER C-75-477 Ex%RATION DATE G/,7.- <br /> WATER TABLE DEPTH: SO t R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST s / BUILDING PERMIT# LAND USE APPLICATION# 1 <br /> TYPE OF WORK: I NEW INSTALLATION 0 REPAIR/ADDITION G ENGINEER DESK NED IALTERNATrvE <br /> LI REPLACEMENT Cl OUT-OF-SERVICE SEPTIC SYSTEM G DESTRUCTION <br /> INSTALLATION WILL SERVE: U RESIDENCE f'COMMERCIAL C1 OTHER —_ <br /> NUMBER OF UVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPErMFG CAPACITY gal N OF COM'ARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE ft <br /> O LIFT STATION SIZE TYPE OF PUMP U PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS N OF LINES LENGTH OF LINES It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> Cl SUMPS WIDTH R LENGTH It DFPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH R DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft i <br /> 0 SEEPAGE PITS NUMBER WIoTH ft OEPTN R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT 1 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 /> M11416M 24 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED 7171.E /e•C-,F DATE <br /> p E <br /> o E N <br /> i <br /> _ I <br /> -- I <br /> DEPARTME T NL aL-O�f—J <br /> Appficsticn Acce Date (vy Area Employee IDs <br /> Final Inspection By ieim��RiKDate 7 / ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to De th of 3 Ft: PIVSump Soil Character. <br /> COMMENTS <br /> PE SC Received Amount Date _ Permit/ Invoice N Permit IDN <br /> Code INFO B Cash Remitted Servlcs Re uest N <br /> �{L2-2 SLI _- 125 [.'v 5>QG� !s 5 ) 79 <br /> ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 42-Cl <br /> Bl27/I C <br />