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VI-11f - ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUND IT+ CALL(2091953-7697 FOR INSPECTIONS j &XPIRES 1 YEAR:66FR T ISSUEQ <br /> JOB ADDRESS L+w.. CITY/21P <br /> CROSS STREET 1 AP4 ^ 1210 � PARCEL SI2{{yyF. 'A yAn a <br /> OWNER NAME - } C /�♦ PHONE 232.55 't _ <br /> OWNER ADDRESS CttY/STATE/ZJP <br /> CONTRACTOR _ PIIONf <br /> CONTRACTOR ADDRESS CITY/STATETLIP <br /> .LICENSE YC-42 ❑C-36 OTHER_ _ NUMBER fitrEXPIRATION DATE VV <br /> WATER TABLE.DEPTH:. ft GEOGRAPHICALINFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION Cl ENGINEER DESIGNED/ALTERNATIVE <br /> t'l. REPLACEMENT Q DFBTRUCT{ON <br /> INSTALLATION WILLSERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBEROF LIVING UNITM3: NUMBER OF BEDROOMS: NUMB£R,OF EMPLOYEES; <br /> ❑ SEPTIC TANK TYPE/MFC+_ CAPACITY gal #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPefMFG CAPACITY gal C OFCOMPARTMENTS <br /> ❑ .PKG TX PLANT DISTANCETONP.ARES7: WELL. It FOLNDATION R PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ �9 IL SEPARATOR(ENCLOSED'Sv <br /> LEACH LINES X LEACHING CHAMBE it OFI.INES LENGTH OF LINES R <br /> DISTANCETONEARE.ST WE � A FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH h LENGT R DEPTH_ ft <br /> DISTANCE TO NEAREST WELL.. ft FOUNDATION it PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION it PROPERTY LINE R <br /> O SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH it DEPTH ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION tI PROPERTY LINE ft - <br /> ❑ SEEPAGE PITS NUMSER WrorH ft DEPTH R <br /> DISTANCE TO.NEARFM WELL R FOUNDATION ft PROPERTY UNE. ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATI01 OF SAN JOAQUIN COUNTY. <br /> SIGNED`j� MINIM~24 �' N, EQLIktC0I.IRIl , 1.1,(2N) <br /> It <br /> A <br /> 11A 66 <br /> J <br /> ': , <br /> i L <br /> DEPARTMENT US .+OP.+L <br /> Appilcatien Accepted By •.. l ate l Area. E7 cqlll� J <br /> Fhud Inspection By to �l �'l o,6 <br /> E3 SPECIAL PERMIT- b G <br /> ChaocterofSoil to of 3 Ft: Pit/,96mp Soil Character: k�p�•.,,;�M <br /> COMMENTS G` I. 5 ON�Ct1F <br /> 9� <br /> PE SC Received C Amount Permit/ InvoIcc# Permit ID# <br /> Code INFO Cash Remitted Date ;Service R uesT# <br /> !1 14 <br /> 42-02-001 <br /> 00 <br /> 1,2=0032=t22/2UO3 ONSITE WASTEWATER PERMIT <br />