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t ONSIT ASTEWATER TREATMENT SYSTERA"RERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTALDEPARTMENT 600 E MAIN$�. �-STOCKTON CA 95202-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS !XP1RE5 I YEAR FROM DATE ISSUED <br /> JOB ADDRESS c 31AX `CITYIZIP L Z� fI1 <br /> CROSS STREET yf L � '/"J/��/�To APN _ ��!~��~124,� PARCEL SIZEHL11 BUY OWNER NAME o�`�rX057`,41VO S PHONE r <br /> CST �LJ <br /> OWNER ADDRESS �� CrTYISYATElZIP I <br /> r f i'Y ��Z •Z <br /> CONTRACTOR I w[JIj � M <br /> lf2�v���, ,,PHONE J '/(P I <br /> CONTRACTOR ADDRESS a`-IG/�/1 4iW arITY1STATErzw �, f.�r 15- r ' <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER ExPIRATION DATE <br /> WoUlk TABLEDEPTN: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST A BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION D REPAIRIADDITION D ENGINEER DE=NED!ALTERNATIVE I <br /> ❑ REPLACEMENT ❑ DESTRUCTION { <br /> ILL SERVE: 17 RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OP LIVwG UNITS: NUMBER OP BEDROOMS: MUMSER OF EMPLOYEES: <br /> O SEPTIC TANK TYPFJMFG CAPACITY <br /> gat #OF COMPARTMENTS <br /> O GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS 1 <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ,� ? <br /> Q LIFT STATION SIZE TYPE OF PUMP D PKG TX PLANT 0 SAND CIL SEPARATOR(ENCLOSED SYSTEM) <br /> 13 LEACH LINES O LEACHING CHAMBERS #OFLINEs LENGTH OF LINES ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Q FILTER SED M UTH ft LENGTH ft DEPTH ft ` <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE ft i <br /> O MOUNDED MM" ft LENGTH ft DEPTH ft ' <br /> DISTANCE TO NEAREST WELL K FOUNDATION R PROPERTYLINE fl <br /> O SUMPS WIDTH ft LENGTH ft DEFTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE ft <br /> C3 DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft ` <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> R SEEPAGE PITS NUMBER WIDTH <br /> ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft. PROPERTYLINE ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCAT10M AND THE WORK WILL BE DONE IN ACCORDANCE VATH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. OC <br /> M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE (209)953-7097 <br /> SIGNED TITLE <br /> DATE <br /> i <br /> V 7 <br /> MID <br /> M NT <br /> T DE P <br /> DEPARTMENT U E ObILY <br /> Application Accepted BY : Date (� Ofe Area Employee ID# 6-3(045 <br /> Final Inspection By [),to I Zf ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil t0 DDept�h f 3 Ft: PitlSDmp Soil Charaet <br /> COMMENTS_<l�&[ � flc� �/�.G ��li/• ins %l`� - <br /> PE SC Received <br /> Code INFO B ash RemCh Amoitteund t Date .rvi:PermlU,est# Permit Invoice A Peit ID# <br /> S <br /> gZ2-7- 52 7 os. 1 p <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMR <br /> 1014177 <br /> ;i <br />