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5;C w IT/°I/(V <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT 1 `II`/- ) ,' 'y <br /> - SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT GOO E MAIN STREET-STOCKTCN CA 95202-(209)468-S 0, <br /> NON-REFUNDABLEPERMIT CALL 209)953.7697 FOR INSPECTIONS p EXPIRES 1 YEAR FROM DATE ISSUED <br /> f� <br /> JOB ADDRESS ppG0I S• LCN MA N r"/ - _ CITYiZIP T{I•-Tl <br /> CROSS STREET 1�L y-�A L��N rnrn APN z-93- 33 G— r 3 P�A1RCEEL SIZE <br /> OWNER NAVE A►�1>"S �W F1•--DEIZ. PHONE TO <br /> OWNER ADDRESS �0) �-' �� CITYiSTATE(ZIP <br /> CONTRACTOR Lt VeyV A,�— &e0j-1 VI("rQf' Cf-ITA(--- PHONE 31y / - 031S— <br /> CONTRACTOR ADDRESS / W' 0/'[fes. St • CITYISTATE)ZIP �"�� z-'-�O <br /> LICENSE C-42 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: II GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> >( PERC TEST #__J_ FBUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE-IMFZ CAPACITY gal #OF COMPAR'MENTS <br /> ❑ GREASE TRAP TYPEINIFS CAPACITYgal #Of COMPARTM=NTS <br /> DISTANCE TO NEAREST: WELL fl FOUNDATION It PROPERTY LIE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LNES ft <br /> DISTANCE TO NEAREST AFII. ft FOUNDATION _ _ ft PROPERTY LINE IT <br /> O FILTER BED WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST AELL ft FOUNDATION ft PROPFRT�LINE ft <br /> ❑ MOUNDED WIDTH It LENGTH IT DEPTH it <br /> DISTANCE TO NEAREST AELL ft FOUNDATION R PROPERTY LINE it <br /> O SUMPS WOTH It LENGTH ft DEPTH tt <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE_ h <br /> O DISPOSAL PONDS WIDTH tt LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST V4--LL III FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTR ft DEPTH-- <br /> DISTANCE <br /> EPTH _DISTANCE TO NEAREST WELL It FOUNDATION It PPOPLH'Y LINE ft <br /> I:HEREBY 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 /> I�tl`A.A1U' HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL(209)953.719' r_ <br /> SIGNED "CTITLE C.ONSUL-TA N r DATE <br /> i <br /> • n=IGKATED REMAINDER- <br /> ;t <br /> = 206 <br /> U �'yEiyT�UN)Y <br /> AA114N T <br /> o <br /> DEPART61ENT USE NLY 1 <br /> Application Accepted il" Area �(�� EmployeelDO <br /> Final Inspection ey Jw Date SPECIAL PERMIT-Approved by <br /> Character of Soil to pth of 3 Pt: ����-� Pi ump Soil Character: <br /> COMMENTS <br /> iii :r� D I�—1 f� �?G l'�c� �-.I.'i-�i.,i-•i'7 � T — <br /> JDate <br /> PE SC Received Amount Permit' Invoice# Permit IDN <br /> Code INFO aih Remit ted I Service Request# <br /> 42-01 ONSITE 17AS7EWATER TRTMNT SYSTEM PERM.T <br />