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r ~ ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENv'IRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3M'FL-STOCKTON CA 95202 - (209)469-3420 <br /> r NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS r D CITYIZIP <br /> CROSS STREET N N� ►"1'� APN '�-�^��, Ii/ PARCEL SIZE ;2 J c o <br /> OWNER NAMEPHONE <br /> 22-9 <br /> �J} <br /> OWNER ADDRESS f-- V CITYISTATEIZIP <br /> CONTRACTOR - //�� `` �]�t} t `}A}L " PHONE <br /> F11 <br /> 4ML-J 95 <br /> CONTRACTOR ADDRESS4006 N ' Y`� It-sO�/ `"" fCCIIyT�SY�IISSTTATk1EIZIP � <br /> +� LICENSE C-42 ❑C-36 OTHERv NUMBER ���cJ •� EXPIRATIONDATE �� Q✓ 1 <br /> WATER TABLE DEPTH: fl GEOGRAPHICAL INFORMATION: Coordinates X Y I^ <br /> F, C3PERC TEST(S) NUMBER LAND USE APPLICATION M <br /> TYPE OF WORK: X NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER I� <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ly NUMBER OF EMPLOYEES: 1 <br /> { t <br />( - � SEPTIC TANK TYPEIMFG �L tJ��Gf CAPACITY gaI f10F COMPARTMENTS <br /> E3 GREASE:TRAP TYPEIMFG ' L� CAPACITY Q gel IIOFCOMPAKTMENTS - <br /> ❑ PKG TX PLANT DISTANCETO EAREST:-WELL -t ft FOUNDATION 5 f3 PROPERTY LINE ! -F ft <br /> Iv__ ❑ LIFT STATION Slz II TVPi?OF PVMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> I <br />{ f—' I< LEACH LINES XLEACHINC CHAMBER 4V� 56 #OF LINES LENGTH OF LINES t.00 ft <br /> DISTANCE TO NEAREST WELL FOUNDATION 1 Oft PROPERTY LINE - ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION It PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> �t 1 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE Ft <br /> i„ ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LLNOTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 /> INIh1 V N NOTICE REQDIRED FOR N PE TEdN5-PI, ASE CALL(?l19}453-7647 <br /> SIGNED TITLF DATE <br /> r. <br /> CqUED <br /> 4 <br /> r _ <br /> I ` _ <br /> 5" <br /> ! ,' O ".('A Cour <br /> r IR N F <br /> 14 <br /> { DEPARTMENT VE LY /, <br /> Applieatiun Accepted By ate L' Are. Employee ID# <br /> Final Inspection By Date L1SPECIAL PERMIT-Appmved by <br /> Character of Soil to th of 3 Et: Pi Sump Soil Character: <br /> I COMMENTS Ja ✓ r r 1 l _ <br /> O 141 <br /> PE SC Received heck41 Amou.1 at Perm itf invoice# Permit IDH <br /> i Cade INFO BY ash Remitted service Request# <br />