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r <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT C��/A�77LL 209 953-7697 FOR INSPECTIONS yyExPPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSt4Lotr'- cn rer <br /> CROSS STREET 1 q Fn C-12L APN V 1 /J3J1 ��^' <br /> j PARCEL SIZE <br /> e <br /> OWNER NAME ��t/S�11"' L 0., v <br /> G / PHONE <br /> OWNER ADDRESS <br /> �� i �/i ^� I CITY/STATEILPLC11''1pO <br /> CONTRACTOR V�/C--� ^^( �J_./�I� ,`/ � �ip�1h C�\�y nc PHONE <br /> CONTRACTOR ADDRESS -J /f IeJ(�•IJ ) �1 l.J� hh / <br /> CITY/STATE/ZIP_ G✓�l�L T-T'• ��'�/l.' <br /> LICENSE L1 C42 _I 'C.36 OTHER_ NUMBER 1 SI ✓-I EXPIRATION DATE 2-V <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> G <br /> 'TEST # BUILDING PER # LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ]] REPAIR/ADDITION ENGINEER DESIGNED/ALT ERNATN <br /> REPLACEMENT S �' IL I6 I`�`` OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION-:X r� - t <br /> INSTALLATION WILL SERVE: RESIDENCE I' COMMERCIAL TI OTHER <br /> ,./ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: +r NUMBER OF EMPLOYEES: <br /> W SEPnC TANK TYPE/MFG -r1w;"0P1q /.j Il�rlv1f"01 j'.CAPACITY 1 U gal #OF COMPARTMENTS 2- <br /> ❑ GREASE TRAP TYPE/MFG -/f)1 W V CAPACITY ,\ gal #OF COMPAR T MENTS <br /> DISTANCE TO NEAREST: WELL�� ft FOUNDATION ft PROPERTY LINE C ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #of LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH_ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMaER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL k 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 ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> M4MUM 4a HO ADVANCE NOTICE1 L (2 09) -76 <br /> SIGNED �' TITLEJO't - - <br /> -�L�.%t,u DATE cT LY-?'I;-)�-_' /1 <br /> FcF��N71 <br /> I V1 I I I <br /> 30 �O <br /> GN IV RONPA I �o �0 <br /> Thp ;IR <br /> /O4,vTy <br /> NT <br /> DEPARTMENT,USE PALLY <br /> Application Accepted B �_ Date_ �' /. Q�Q Area Employee ID# <br /> Final Inspection By Date VSPECIAL PERMIT•Approved by <br /> Character of Soil to p h of 3 Ft: Pit/Sump Soil C aracier: <br /> COMMENTS 17 <br /> a:� `LV y t. 17y:-,1 �,l m f C 0, <br /> PE SC Received Check#( AmountDPermiU <br /> ate Invoice# Permit ID# <br /> Code INFO Cas Remiked Service a uest# �e� <br /> 4201 /� �fJONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> a 1 TY4114118 �J/ <br />