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Id <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL-t H DEPARTMENT 304 E WEBER AVE-3"FL-STOCKTON CA 95202 -(209)46l-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 17 b S: So � CITY/ZIP <br /> CROSS STREET r v1 -�- APN a 7 fp-.1?00-37 PARCEL SIZF: <br /> OWNER NANIe /yle�t>�t 1yIP�a/,�s /i�l�+ S If Draearl-. "103538 �}P�,o,, 5-26433s, <br /> OWNERADORE55 �s'p49 �Qr1/p11�� //C/�J – CFTY/STATFJZIP 6 ' <br /> CONTRACTOR _ jj l��i PHONE ttvvtt <br /> CONTRACTOR ADDRE:S CITYISTATFJZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: Il GEOGRAPHICAL INFORMATION= Coordinates X Y <br /> ❑ PERC TEST(S) NL'MUER LAND USE APPLICATION# ) <br /> TYPE OF WORK: X NEW INSTALLATION O REPAIPJADDITION ❑ ENGINEERDLSIGNED/ALTERNATIVE <br /> wr REPLACEMEENTT Q DESTRUCTION FY^} <br /> INSTALLATIONWILLSERVE:— 3e-RESIDEVCE ❑ COMMERCIAL ❑ OTHER_ L' <br /> NUMBERorLIVINCUNITS: I NUMBER OF BEDROOMS: 3 NUMBER or EMPLOYEES: ^l <br /> D"/SEPTIC TANK TY PE/MFG_ (r)V) tie- CAPACITY U gal V OF COMPARTMENTS <br /> 1 <br /> I ❑ GREASE TRAP TYPEMSFG CAPACITY_ gal LL OF COMPARTMENTS <br /> Q PKG TX PLANT DISTANCE TO NF-ARE.-F: WELL R FOUNDATION h PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> XLEACH LINES ❑ LEACITINC CHAMBERS 0 OF LINES 3 LENGTH OF LINES t R <br /> DISrANCE To NEAREST WE;.L > _ft FOUNDATION ._ft PROPERTY LINE �/ 00 <br /> O FILTER BED WDJTII ft LENGTH — _ft DEPTH__ tt <br /> DISTANCE TO NEAREST WELL Il FOUNDATION ft PROPERTY-INF. 1t <br /> ❑ MOUNDED WIDTH R LENGTH _ R DEPTH R �p <br /> DISTANCE TO NEAREST WELL R FOUNDATION, R PROPERTY LINE R 0 <br /> O SUMPS WIDTH _ft LENGTH ft DEPTH R 3 <br /> DISTANCE TD NFAREST WELL__fl FOUNDATION _ ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETONEARESr WELL ft FOUNDATIJN it PROPERTYLINE_ R <br /> ❑ SEEPAGE PITS WIDTH ft LENOTH ft DEM R <br /> DISTANCE TO NEAREST WELL ft FCUNDATION ft PROPERTY LINE R <br /> 1 HERYBY CERTI TT I HAV PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> S TE LAWS AND RULES AND REGULATIONS OF SAN'JOAQUIN COUNTY. <br /> M CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Ll�.+! Q�" DATE v _ <br /> I <br /> i <br /> I 1'.�/ <br /> l _ <br /> - i — - <br /> I <br /> r% <br /> DEPARTMENT USE ONLY ^ Q -y <br /> Appikation Accepted BY PA&V_...... ( <br /> _—_-. Date b I / '�� Arca L. Employee lDO— + IIf <br /> Final inspection By_ Dale 2. s -,_ 13SPECIAL PERMIT-Approved by _ <br /> Character of Soil tc h or Ft: Plt/Sump Soll Character. <br /> COMMENTSVL�q.) // /5r-y /L�vL, d7�- z �, . <br /> PE SC Received Amount Pcrmiv <br /> Code INFO Cash Remitted Dere lovoke V Permft IDrI <br /> rzl 11-7 3-U3 Z <br /> 42-01-001 ONSITE WASTEWATER PERMIT <br /> 12/-02 <br />