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4-V <br />ONSITE.WASTEWATERTREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E <br />WEBER AVE -3" FL- STOCKTON CA 95202 - (209) 468-342D <br />NON-REFUNDABLE PERMIT <br />(209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />�j' nCCALL <br />JOBADDRFSS ``ISS - �P�-%�])'� <br />CITY/ZIP------------------------- <br />ITY/ZIP <br />CROSS STREET APN �sr-,�z G - d.E. PARCEL SIZE G� <br />o <br />fw _ <br />OWNER NAME <br />PHONE <br />m <br />-y '�y.�1,A <br />OWNER ADDRESS J0o IL�Ilr�cy <br />CITY/STATFJZIP i✓f <-�A <br />`e <br />CONTRACTOR L <br />P`H1ONE'_r�4:� <br />`.1-J.1 <br />CONTRACTOR ADDRESS uy IE" t•_ CITY/SFATEIZIP ST I � s`LA.S�l1j S •-1J V <br />•L} <br />LICENSE ❑ C42 Q C•36 OTHER NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: R GEOCRAPHICALINFORmATION: Coordinates X Y <br />Q PERC TEST (S) NUMBER LAND USE APPLICATION Yr <br />TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESICNED(ALTERNATIVE <br />rENGIN�E.�E.R <br />❑ REPLACEMENT DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBEROPBEDROOMS: NUMBER OF EMPLOYEES; <br />❑ SEPTICTANK TYPF/MFG CAPACITY— gal #OFCOMPARTMENTS <br />❑ GREASETRAP TYPF/MFG CAPACITY go] # OF COM PARTMENTS <br />❑ PKG TX PLANT DIST.ANCETO NEAREST; WELL R FOUNDATION ft PROPERTY LINE <br />ft <br />❑ LIFT STATION SIZE TYPE OF PUNIP Q SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES ❑ LEACHING CHAMBERS # OF LINES <br />_ LENGTH OF LINES ft <br />DISTANCETONEAREST WELL R FOUNDATION tl PROPERTY LINE ft <br />❑ FILTER BED WIDTH R LENGTH n DEPTH <br />- <br />R <br />DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />1 <br />N <br />❑ MOUNDED WIDTH R LENGTH R DEPTH <br />ft <br />DISTANCE TO NEAREST WELL R FOUNDATION_ft PROPERTY LINE R <br />LY <br />❑ SUMPS WIDTH R LENGTH ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION R�1 <br />PROPERTY LINE R <br />IA <br />❑ DISPOSAL PONDS WIDTH ft LENGTH R DEPTH ft <br />WmNCETO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br />❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH <br />fl, <br />DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />+{1 <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />ATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />DV NCE NOTICE REQUIRED FOR INSPECTIONS -PL <br />CALL (209) 953.7697SIGNED44,-M <br />1A62 <br />�,ASE <br />TITLE � ir/V, DATE <br />DEPARTMENT USE ONLY L / <br />Application Accepted By�—� Date li Area f Employee ID#�-.3_. <br />Final Inspection By Date 7 U ❑ SPECIAL PERMIT. Approved by I <br />Character of Sailtu epthof3Ft: Pit/SumpSoil Character; <br />COMMENTS AJ 4.,— k +r c o t ,.A(,, <br />PERecelved Check#/ Amount Permit/ <br />Code I INSC FO By. Remitted Invoice At Remitted Service H uest # Permit ID# <br />2.Z1 ops Z L 151<60 3`? ),z --i <br />-ol.Dm <br />znt ONSITE WASTEWATER PERM11 <br />