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i 1 <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT --- 304 E WEBER AVE-Y"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 ADDRESSa`t( / D I,C9�.CL��. S 11 CITYrz., <br /> CROSS STREET ��� J}J^JVf T'f't" APN0 a q PARCEL SIZE <br /> OWNERNAME (/A/J�/("t�ll��, fT-ItA`r`�r�✓ PHONE 2 U � <br /> OWNERADDRESS �QI S�VW YL� ^ CtTYISTATEFZu, QS i e <br /> 3 <br /> CONTRACTOR �„��S <br /> i <br /> CONTRACTOR ADDRESS 1�QC,QS ("�'�(� ^,I CITY/S[T�ATFJZIP <br /> LICENSE ❑C-42 NUMBER 1-36 OTHER 11 49 4 (S O <br /> 1 1 EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y N <br /> ❑ FERC TEST(S) N2IMBER LAND USE APPLICATION# <br /> TYPE OF WORK: 0— NEWINSTALLATION ❑ REPAIRIADDrr10N ❑ ENGI EERDESIGNEWALTERNATIVE } <br /> ❑ RCPLACEMErNT Q DESTRUCTION <br /> � <br /> INSTALLATION WILL SERVE: ZFRESIDENCE ❑ COMMERCIAL ❑ OTHER_ <br /> NUMBEROF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> i13r SEPTIC TANK TYPE/MFO_ CAPACRY (lJy gal itgPCOMPARTMENTS <br /> ❑ GREASETRAP TYPE/MFG _ CAPACITY gal #QFCOMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDAr10N ft PROPERTY LINE fl <br /> ❑ LIFT STATION SIZE TYPE OP PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> —lot <br /> LEACH LINES ❑ LEACHING CHAMBERS p of LwFs�_— LENGTH OF LINES 25 ft <br /> DISTANCE TO NEAREST WELL _ft FOUNDATION I _ft PROPERTY LINE tl <br /> ❑ FILTER BED WIDTH ft LENGTH 12 DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH _ft DEPTH ft <br /> DISTANCE TO NEAREST WELL—_ft FOUNDATION A PROPERTY LLNE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL _ft FOUNDATION_ ft PROPERTY UNE ftE3ENGTH DISPOSAL PONDS WIDTH I ft Lft DEPTH ft <br /> DI5rANCY TOt NEAREST WELL _ft FOUNDATF N ft PROPERTY LINE S <br /> 1�,, SEEPAGE PITS WIDTH ",D II ft LENGTH ft DEPTH a S it <br /> DISTANCE TO NEAREST WELL. (7 —ft FOUMJA'TION' fl PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL DE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULA71ONS OF SAN JOAQUIN COUNTY- <br /> y1 MINiMUNI 24 HOU ADVANCE NOTICE.REQUIRED FOR INSPECTIONS-PLEASE CALL(209053-7697 <br /> � <br /> j SIGNED TITLEr <br /> DATE�J t4 <br /> — - <br /> I <br /> I <br /> I U <br /> I <br /> I <br /> DEPARTMENT USE ONLY M3;4 <br /> Application Accepted By ^'�+v- Date 4����G Arcs Employee lD# (� 9 <br /> Final Inspection BY_ Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to epth a U p Soil horst r• <br /> COMMEN Sjl, / <br /> 'f ocu�v r'fJl 03 <br /> PE SCReceived Checw Amount Dale lnvaiee# Permi[ID# <br /> Code INFO B as Remitted Service R uest <br /> 142.t 1 11'? ik30Zr 320 ov l TeOo S7o3 <br /> 42-01-OOT <br /> 12/'1102 ONSITE WASTEWATER PERMIT <br />