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Z 3 PEARL P-T) • owp kCAwt Po S2-O JOB ADDRESS <br />CROSS STREET --JIN 1-11;"" Is-rr g-1) • APN co 3- - .2-9-o - cz_ PARCEL SEE 2. (Q6 A-C • <br />OWNER NAME <br />REPLACEMENT 0 DESTRUCTION <br />0 OTHER <br />NUMBER OF EMPLOYEES: <br />INSTALLATION WILL SERVE: C RESIDENCE <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />COMMERCIAL <br />P€L PAT) t.) o PHONE ClOir Fre‘t-C <br />OWNER ADDRESS <br />CONTRACTOR <br />$,pstfvk C <br />GEO E&S KO F-'114 <br />CITY/STATE/ZIP <br />PHONE 3(175 03 9--S- <br />NUMBER EXPIRATION DATE LICENSE EC-42 LC-36 OTHER <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />BUILDING PERMIT # LAND USE APPLICATION # <br />REPAIR/ADDITION 0 ENGINEER DESIGNED /ALTERNATIVE NEW INSTALLATION TYPE OF WORK: <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 />WATER TABLE DEPTH: <br />PERC TEST # <br />CONTRACTOR ADDRESS 1+01- te•-) • 0 PO4- c-T . cmasTATErzip 1---•917) I 9 <br />SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />GREASE TRAP TYPE/MPG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION <br /> <br />ft PROPERTY LINE <br /> ft <br />LIFT STATION SIZE TYPE OF PUMP D PKG TX PLANT CI SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES 0 LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />FILTER BED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />MOUNDED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />SUMPS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION 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 />MINIMU OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE DATE - - 61 <br />—7 <br />< <br />1 6'1 <br />I I <br />5 <br /> /4 <br />_1 <br />441, V <br />I I <br />1•1 <br />DEPARTMENT USE ONLY <br />Application Accepted By ' i Date it -L/z.op? Area LE r( Employee ID# <br />I Final Inspection By Date 0 SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft Pit/Sump Soil Character: <br />COMMENTS PA- I <br />PE <br />Code <br />SC <br />INFO gy,9,{ <br />Received .....ilecai6-.4" Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Permit ID# <br />ash , <br />4-2.2/ 52,-.5 t://g-,L /7/0 /52- IN/q Sr (4103g/ <br />42-01 <br /> ONSITE WASTEWATER TRTNINT SYSTEM PERMIT <br />iAJ )