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jo <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-31p FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIO.Ns EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 6/� �G. S. Gt./ -1611CITY/ZIP <br /> CROSS 37'REE7' _1! � / ,,L��l�C .l.4si/ APNQPARRjCEL SIZE�j—lla1�_ o <br /> OWNER NAME vp� �/ //(/C �f7j /� PHONE_ /%73 =jiL 0 <br /> } y <br /> OWNER ADDRESS CITY/STATEIZIP <br /> CONTRACTOR PHONE J '� <br /> L CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICFTSE C42 ❑C-36 OTHER_ NUMBER ERPIRATION DATE. <br /> WATER TABLE DEPTH: ft GEOCRAPHICAL INFORMATION: Coordinates X y <br /> ❑ PERC TEST # BUILDING PERMIT# _ LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITLUN ❑ ENGINEERDESICNED/ALTERNATivE <br /> ❑ REPLACEMENT ❑ DESTRUCTION ate. <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER COCA <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS' NUMBER OF EMPLOYEES: 4'; <br /> ❑ SEPTIC TANK 'TY?L/MF I--__ CAPACITY gel #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPPJMFO. CAPACITY gal #OF COMPARTMENTS }V� <br /> ❑ PKG TX PLANT DISTANCII TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE _ ft <br /> ❑ LIFI'STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES A LEACHING CHAMBERS -- #OF LINES LENGTH OF LINES It <br /> DISTANCE TO NEAREST WELL ft. FOUNDATION ___Ii ft PROPERTY LINE h <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL _ ft FOUNDATION_ ft PROPERTY LINE f� <br /> ❑ MOUNDED WLDI'H ft LENGTH__ft ft DEPTH ft <br /> DISTANCE I'O NEAREST WELL ft F uDAFION_ft PROPERTY LINE R <br /> SUMPS Y3 WIDTH it LENGTH ' ft DEPTH_ ft <br /> DISTANCE TO NEAREST WELL, P CW It FOUNDATION � ft PROPERTY LINE ' $ <br /> O DISPOSAL PONDS WIDTH fl LENGTH ft DEPTH Q <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE It <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TU NEAREST WELL ft FOUNDATION— fl PROPERTY LINE: ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE,LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, <br /> N NIM; 4 HO ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2091 953-7697 <br /> SIGNED p- <br /> TITLE Ce[./Lv o.� DATE <br /> -177 <br /> r.. <br /> L <br /> NOI N <br /> Ef V11 0 mt 11 <br /> v <br /> u: <br /> r <br /> DEPARTMENTU' ON Y' <br /> Application Accepted By Date Z 61a Arca Employee IN <br /> Final Incpectioa By <br /> to_ � 0 SPECIAL PERMIT-Approved by <br /> Character of Sol]to Depth o PiUSump Soil Character: <br /> COMMENTS <br /> PE SC Received Ch Amount Permit/ <br /> Code INFO B Caeh Remitted Date Service R uest# Invoice# Permit ID# <br /> 73- <br /> az-Dz- <br /> 12!2Z12003c%y,r.� � � ,�JJ iZ� u✓.- 4vi� o air �Sc,�.c, ,,��--• _ .� <br /> �e-+1`.-» ��iex�.— � �-vy- '�•r'" "x�%�r��c.-� .G2»+G ems, .+f:-s,<,�� -'�'-�f'1 <br />