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"� r,r NEM,17 <br /> ( •,� N, <br /> SAM JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 E.I-IAZCLTON AVENUE-STOCK"rom CA 95205.(209)dGo-3420 <br /> `IOM REFUMDABLE PERMIT _ CALL20.9 2.5*1 j 7P7_r-ort Imsnccrronrs _ ExPIRES 1 YEAR FROpit BATE ISSUED <br /> Jon ADDRESS -.1�.Z� Kr•G•� f//e CITYI7_IP e/ <br /> C, n <br /> I OS•STREET <br /> -L A,P'N '�2 �) -Z 10 PARCEL S17F <br /> ^INPII:R'IAME: PHONE - <br /> OWNER ADDrr55 7,0(� Vl God ALT,-_�L ( CITY/STATr17-v, <br /> T <br /> CnI-ITRACTnr. C _PHONE 3�5-SaL7 <br /> CONTRAG Tor ADDRESS 37yre w ��/e U1/G CITYJ TATEIZIP <br /> LICENSE_ I,OCC-42 UE,IC-36 OTHER Num BER EXpIRATION DATE ZQITO�L/ <br /> 'WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: COOI'C111I MeS 1' <br /> 0 PF_RC TEST # LAID SOERPAI I d} LAID USE APPLICATION t <br /> -YPF OF IA!OR'S: •• NEW INSTALLATION 0-REPAIWADDITION 1.1 ENGINEER DESIGNED IALTERNATIVE <br /> REPLACEMENT I TOUT-Or-SFRVICE SEPTIC$/STEM U DESTRUCTION <br /> IPSTA LLATION(WILL SERVE: f l RESIDENCE_ CIAL 171 OTHER <br /> i`IUMBr•R Or LIVING UNITS: 'NUMBER Or BEDROOMS: NUMBER OF F_MPLOYEES � <br /> C SEPTIC TAMK, TvrE/Mr-..i CAPAr111 gal i/OFCOMPAP.TMEHTS <br /> r CREASE TRAP TYPE/Mrr, CAI'A(:IT`i gal iP OF COMPARTMENTS <br /> DISTANCC TO NEAREST: WEU- 11 FntrHOATION_ 'fl PROPERTY LIPID fl <br /> LIFT STATION SIZE TYPE OF PUPIIP D PICG T1f PLANT _O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> f LEACH LIMES ' LEACHING CHAMBERS 9 o Lu•IEs LENGTH OF LriFs it <br /> DISTA14CE TO NEAREST 1A/I LL_ II 1--nN II`InATIOPI fl PP.OPF.RTY LINE it <br /> r FILTER BED INII)TLI it I-EIaG'11-I (I DEPTH fl <br /> DISTANCE TO NEAREST lNl7.l_ II RJUIdI'rA rinhl fl PROPERTY LINE ti <br /> r MiOWDED IWIDTrl_ It LEPIGiPI It DEPTH fl <br /> DISTANCE 1'0 NEAREST WELL it FntIND.AI'IOId _fl PROPERTY LINE it <br /> F7 SUp4PS IA4nin fl LEPIr;rPI fl DEPTH f1 <br /> DISTANCE TO NEAREST WELL It FI IUI`IL)A Ul.IPI It PROPERTY LINE it <br /> I? DISPOSALPO'!DS lAlinT1I It UrNI;n1 It DFPI'H it <br /> DISTANCE TO NEAREST WELL fl PIXIMPATION II PROPERTY LINE ft <br /> G SEEPAGE_PITS IdunaerR WIDTH Il DEPTH it <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE it <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ARID THE WORK WILL BE DONE IN ACCORDAOCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> 1141hiffiiUN11 it3 HC-UF AD%1A1,,fCE NOTICE FE0 1JIRED FOP 1AISPEC)IONS--1'1 EASE CALL(7091 953-7691 <br /> SIGNED TITLE nATE/W�/,� 9, <br /> --- — --- — l - — --- — <br /> --- - - --- ---- - ----- - - -- - - - 19 <br /> _ , <br /> --------- — -- Dcr-Ar.r114.FA!T Js 0A)LY p�Ey UNry <br /> Application.Accepted By Datn ?i Area Employee ID# <br /> Final Inspection By Dale. O SPECIAL PERMIT-Approved by T <br /> Chericio-of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> C01MIMENTS�(�� llil/�GT <br /> PE SC Rcccived C110001 Amount Permit! <br /> Date Invoice fS Permit IDiI <br /> Godo IIyFABy Gash Remitted _ ScrvfceRequcsti! <br /> •L'-n I <br /> ONSITEWASTEWATER TRTMNT SYSTEM PER K4IT <br /> IlI•I!I:� <br /> 4 <br />