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1& <br /> 415`- v �6Wre WASTEWATER TREATMENT SYSTEM PERMIT <br /> 4P <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELToN AVENUE-STOCKTON CA 95205-(209)468.3420 <br /> NON-REFUN S4IP�EER�M7IITTCALL 209 953-78 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS _ � IL.tL[ L2" 7`a.,�...�,......._ - m <br /> -s_. ..__ ..._ ,1._._ ,. ...._....—......__-„.....,.,..CITY/Zlp,-Li . �...._._.__ _....—.. <br /> CROSS STREET 1�.✓�-" ;.;— V.. APN. .......... �_ _._.._.1,2._... <br /> ..................... PARCEL SIZE_....._..... r S <br /> OWNER NAM ... qmm�� A4�!_ .+__ _ IONe.._i�.✓..ii—i—+-F.�.r_.i-.S�..L z <br /> OWNER ADDRESS CrrY/STATEIZIP <br /> -- -(�_..._______...... <br /> CONTRACTOR D, = <br /> „� _ 3 C i _ .._. ........_.PHONE.–.(,yam!-&-.�— <br /> r. <br /> CONTRACTOR ADDRESS _ CfTY$TATE/ZIP <br /> LICENSE 'iC-42 El: C-36 OTHER—k— NUMBER AM EXPIRATION DATE.��Y” <br /> WATER TABLE DEPTH: _ it GEOGRAPHICAL INFORMATION: Coordinates X _ Y <br /> 7 PERC TEST # �[ BUILDING PERMIT# _Q. _ LAND USE APPLICATION# <br /> TYPE OF WORK: X NEW INSTALLATION REPMR/Anosu)N ENGINEER DESIGNED/ALTERNATIVE <br /> .. REPLACEMENT _....-�— W. OUT-OF•SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: T RESIDENCE i`i COMMERCIAL 1 OTHER_,--_ _ <br /> NUMBER OF UyING UNITS: NUMBER OF BEDROOMS: ......._.. ________....... NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPEJMFG ................... CAPACITY j=­­­- gal #OF COMPART'MENTS–-2---..._._ <br /> ❑ GREASE TRAP TYPE/MFG y– CAPACITY-_ _.-_�._-___ gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELLAI.5-t....__ it FOUNDATION 15-- ft PROPERTY LINE ._%� it <br /> ❑ LIFT STATION SIZE --,..—_TYPE OF PUMP___ ❑ PKO TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> I� a <br /> XI LEACH LINES LEACHING CHAMBERS­4� _ _ It of LINES_, _ LENGTH OF LINES it <br /> DISTANCE TONEAREST WELL ft FOUNDATION ____-ft PROPERTYLINE_­_,1�4'it <br /> ❑ FILTER BED WIDTH it LENGTH.__..._-............-_._........... __.....__...._... ft DEPTH_._____.......__....... it <br /> DISTANCE TO NEAREST WELL ._It FCAMDATION __ft PROPERTY LINE_,_,_,._ it <br /> ❑ MOUNDED WIDTH _.­.._____---.ft LENGTH_Mit DEPTH it <br /> DISTANCE TO NEAREST it FOUNDATION–,_ il PROPERTY LINE it <br /> ❑ SUMPS WIDTH...._..................................__._it LENGTHft DEPTH._�..- --_ it <br /> DISTANCE TO NEAREST WELL--.---.-. it FOUNDATION _it PROPERTY LINE,,,__–___—--.it <br /> ❑ DISPOSAL PONDS WIDTH it LENGTH.____..._... ._.....__.__....._...__________ft DEPTII___--___.._--.__-__.._..-.-........ it <br /> DISTANCE TO NEAREST WELL_ .._...... ft FOUNOATION �&f <br /> ft - PROPERTY LINE__. it <br /> .)d SEEPAGE PITS NUMBER _La— WID HJ�.,•,.��_}_, _ DEPTH It <br /> DISTANCE TO NEAREST WELL_IDIN /' it FOUNDATION,�– ft PROPERTY LINE it <br /> i HE REBY 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 /> 4 R T I finR 1 NSP1 EASE CALL LW[9�53- 687 <br /> SIGNED -VU, TITLE _. L ..-._—... DATEV.._. ..-._...._ <br /> ` /IDI r►. 4O <br /> Ap <br /> AO <br /> b <br /> ;4425, u a✓ fy,10, �AP ��+ y <br /> Gd- <br /> `✓POD <br /> - Mt3D A <br /> d. DEPARTAI N USE ONi y ,y _ <br /> Application Accepts -- Data __- Area frm <br /> FinallnspecHon �_ Date_ SPECIAL PERMIT by _ <br /> fY ---- <br /> Character of Soil to pth of 3 Ft: _—_ __. Pit/Sump Soil Character:._ _,,,,,, <br /> all <br /> COMMENTS 2 ` . , ��1 _.. __.__ -9M <br /> ----__. _..___.---/----.. .._—__ Ft4ytRt7#AEfCTAL <br /> PE SC Received ack#/ Amount r- Permit 1—" <br /> Data Invoice# Permit iD# <br /> Code INFO B.. Remitted Service Request# <br /> 3 2_ 4r�3 +1=646 <br /> 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4124/'12 <br />