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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT /G�tl <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 104E WEBER AVE-3"FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 'T p'� /S r //a A(A — <br /> CITY/ZIPW <br /> CROSS STREET <br /> PN �/�t•v! -^ .?..��—far 5 Y <br /> PARCELSIZE�' o <br /> v <br /> OWNER NAME �.__T i�G u- h/✓1 S t R '0 <br /> PHONE j%' (J <br /> OWNER ADDRESS - II 7S/ /�/. -'I`hCIC "7hiwt S lL CITY/STATE/LIP C I'} ( � �] C.t <br /> CONTRACTOR .dl�.� C r'f7,/V -jr7 <br /> -S /)C /I nil J L1.4.,A16-Q-. 1 PHONE � <br /> CONTRACTOR ADDRESS (�,^ I� — CITY/STATE/ZIP <br /> LICENSE- ❑C42 C-36 OTHER NUMBER <br /> EXPIRATION DATE /10"y I d <br /> WATER TABLE DEPTH:— ft GEOGRAPHICAL INFORMATION: Coordinates X <br /> 1' <br /> C FERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> r��NLIM�DCROF <br /> ILL SERVE: M REsIDENcE ❑ COMMERCIAL ❑ OTHER T v <br /> IVING UNITS:_ J� _ N UMBER OF BEDROOMS: NUMBER OG EMPLOYEES: <br /> SEPTICTANK TYPE/MFG,—(��i,/(+( -�IF' CAPACITY_ I CJ D gol 90FCOMPAATMENTS <br /> Ca CREASE TRAP TYPFJMFG_ CAPACI'TY <br /> EaI #OF'COMPARTMGNTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION <br /> _ R PROPERTY LINE R <br /> ❑ ulrr STATION SIZE TYPEOn PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 6� LEACH LINES L] LEACHING CHAMBERS #Or LINES LEN TH or <br /> K <br /> ` DISTANCE TO NEAREST WELL_ I Lf C) LINes_ It <br /> R FOUNDATION R PROPERTY LINE C It <br /> LI FILTER BED WIDTH R LENGTH __ <br /> ft DEPTHft <br /> DISTANCE TO NEAREST WELL_ R FOUNDATION ft PROPERTY LINF. <br /> LI MOUNDED WIDTH f[ <br /> ft LEl'IGI}I _ft DEPTH R <br /> DISTANCE TO NEA REST WELL_- R FOUNDATION ft PROPERTI'LINE }t <br /> 13 SUMPS WIDTH ft LENGTH R DEPTH <br /> R <br /> DISTANCE TO N BAREST WELL _R FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH R DEPTH_ <br /> R <br /> \D�I,STANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE. R <br /> SEEPAGE PITSCZJ^IDTII �� IY R LENGTH ft DEPTIf ..2-S R <br /> / Z— <br /> DISTANCE TO NEAREST- WELL /AF✓1 }1 FOUNDATION ft PRDPF.RI'Y LINE ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK,WILL BE DONE 1 N ACCORDANCE WITH SAN JOAQU IN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQLTN COUNTY. <br /> / NHNI VIUN124 1/I�/p/,�UR ADVAACE NOTICE REQUIRED FOR IN5PECPIONS-PLEASE CALL(209)953.7697 <br /> SIGNED :•'t�� :r wil / �—� T _ TITLE_b t�/ Pts/ /S DATEZ — -O I-- <br /> I OS <br /> 1 � 1 <br /> XF <br /> o- to 2 <br /> , 1 <br /> w � n � n�• *� <br /> cz — <br /> i <br /> Z P <br /> t- ry t h 'C <br /> I S m .i •C O <br /> O 3 <br /> oto o Sp1S <br /> \ �M O l <br /> 11 N 4A Y <br /> 0 <br /> l n m ro .OS 4 <br /> .069 <br /> ;o m <br /> ,�x — <br /> n A <br /> 1 1 1 1 1 1 I I I fT77—�I�I�I-fi� �I�I-� -� <br /> DEPARTMENT USE ONLY <br /> Application Accepted D- <br /> -- Uate / /(o_+Q _ Arca_ 2-f 7 Employee IDIP _S_-34%L, <br /> Final Inspection Date /t7 ❑ SPECIAI,PERMIT-Approved y^_ <br /> Character of Soil tr, epth 3 Ft: <br /> PiUSump Soil Character.—�� .,.,., <br /> COMMENTS U t e� to f u I _sA�S¢' 4fpy S ?d hc. 6,L� [i.•,, , 1� _� .erg` <br /> I /� �����.t/ X c�7—tom �n �-~�r�•n d ,��� �3� �� <br /> PE SC Recelvcd heck#/ AmountPeemlU <br /> Code INFO B Da to J Remitted Invoice C�a•I D4 <br /> '�2.ii 117 ry cc R¢t ucs .af <br /> 4-01-001 <br /> 121]/02 <br /> ONSITE WASTEWATER PERMIT <br />