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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN Cot NTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3-FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT 4 CALL(209)953-7697 I-OR INSPE(IIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/Z;P �/7� �J4�V EV <br /> CROSS STREET APN 4-' �/ ~r S PARCEL SIZE •�/TL <br /> D <br /> OWNER NAME &&LIR/•1 RA771I(2cyl-160 PHO!.F do 1 560 <br /> OWNER ADDRESS !!♦7/L�r/s/,/��//, —90i("_ CITI'/STATE/ZIP��7��' <br /> CONTRACTOR PHONI- /S46C <br /> CONTRACTOR.ADDRESS CITY/STATT./ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NU MR ER E%PIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRU(TION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NCMBER OF LII'ING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY _ gal N OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEARE.NT: WELL ft FOUND.AI IONft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #of LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE <br /> ❑ FILTER BED WIDTH H LENGTH _. ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH 11 LENGTH It DEPTH R <br /> �1 DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> SUMPS W'IDT11 (/ R LENGTH /t7 R DEPTH /�/ fl <br /> DISTANCE TO NEAREST WELL 1Lf_ft FOUNDATION R PROPERTYLINE R <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE A <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DLPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCE ATE LAWS AND RULES AND REGU�S� ,F SAh'JOAQL'IN COUNTY. <br /> NINIMIIh OlI D .ANC'NU'fICE Rt:QUfRt:D FON IN -PLI:.ASECALi.I'_OV)953-76V7 / r�'SIGNS TITI- DAT/ <br /> 'moi <br /> 1 <br /> 11 <br /> A <br /> u <br /> 511tTZt4fAE1 <br /> N <br /> 4A1. I <br /> 7 p,(EPA RTMENT till ET40 <br /> A <br /> Application Accepted By _ �7�J' Date 2 7/1 Area Employee ID# <br /> Final Insp"I By Dale SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Flit/Sump Soil Character: /T <br /> COMMENTS Q� (ol c� f�(�b D 1Fezi&x P_iE1L'�� io� A5Y r diE��1V 11G1f' <br /> AV,') S CcZO 0)T M54,�r/kG -r#r OFF A, TNF 6AWrK )VIU FAX 8Cl/f C/Pn <br /> ,-eR RO' )EL;1r6-45D TL' ,lf/i 5% 4WO /Z Z:3 c�5.- ,PFZ i�1C41 A91,4 <br /> PE SC Received w- Amount Date Permit/ Inloice# Permit[DO <br /> Code INTO By s Remitted rvlce Req uest N <br /> Z z30 05 <br /> 42-02.001 ONSITE WASTEWATER PERMIT <br /> 121Z2'2(W <br />