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ONSITE WASTEWATE- REATMENT SYSTEM PERMIT <br /> rANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT `W 304E WEBER AVE-3°°FL-STOCKTON CA 95202 91J69)"11-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR LYSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 'OU ADDRESS CITY/ZIP a <br /> fJ //y' JC/L <br /> L aoS55TREP1' /� JS l 11 1y I�_QTnI`' -1 APN —I1a1l�L/7 ? PA12'eL SIZE o <br /> OWNER NAME M� E I ,� I�j�t PHONE <br /> OWNER ADDHENS CITY/STATE/T.IP �J <br /> :ONTMCIOR T Laia PHONEIZ 1p-:1 1�P-J 1J�1 <br /> OI t A' <br /> COM'IGCEOR ADD0.E55 CRV/STATF/ZIP <br /> 13CA2 13 C-36 OTHER NUMBER EXPIRATIONDATE y <br /> NATER TABLE DEPEH: R GEOGRAPHIGLINPORMATION: Coordinates X— <br /> Ot <br /> Y <br /> PERCTEST # BUILDING PERMIT# LAND USE APPLICATION# - <br /> TYPE OFWORK: ❑ NEW INSEALWTION ❑ REPAIR/ADDMON ❑ ENGINEER DESIGNED/ALTERNATIVE [� <br /> ❑ REPLACEMENT ❑ DESTRUCTION S'T- <br /> `NSTALLATIONIL <br /> WL SERVE: LI RESIDENCE ❑ COMMERCIAL LIOMER <br /> r NUMBER OF LIVING UNFES: NUMBEROFBEDROOMS: NUMBER OF EMPLOYEES: <br /> '] SEPTIC TANK TYPEIM1IFG CAPACITY gal #OFCOMPARTMENTS rJ <br /> GREASE TRAP TYPEAMFG CAPACITY. Sul #OF COMPARTMENTS <br /> PKG TX PLANT DISTANCETONEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SO TYPEOPPUMv ❑ SANDOILSEPARATOR(ENCEOREDSYSTCM) <br /> ,Seel LEACH LINES ❑ LEACHIINGCHAMBERS Nafl.rbu LENGTHoFLINEE R <br /> DIEFAN"TONGmnE WELL ft FOUNDATION ft PROPERTYLINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCETONEARF81' WELL ft FOUNDATION R PROPERTY LME RSSSJ J <br /> MOUNDED WIDTH ft LENGTH ft DEPTH ft(� <br /> DISTANCETONEARxsr WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ SUMPS WIMx ft LENGTH It DEPTH R <br /> DISTANCETOPHAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> ] DISPOSAL PONDS W. ft LENGTH R DEPTH ft <br /> r <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ SEEPAGE PITS Nom.ER Wmm R DEPTH ft <br /> DisTANCETONEARI WELL ft FOUNDATION R PROPERTY LINE R <br /> r I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> M I NIM CM 14 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-0697 .�t <br /> :IGNED `z /-1 ' TITLE DATE 11 1 '� .t <br /> PAS <br /> SE <br /> I1E� 4 <br /> ` 's 3oAu1 u <br /> sANwe <br /> j 7565,1p ENVIHON <br /> 472.33' 344.21' �3"16'0A EALTN <br /> T A <br /> A <br /> �c' <br /> 1.15q2.41' 481.02' 502.74' 59 <br /> EFowuLai-� � <br /> �e DEPARTMENT USFp,NL <br /> AppliuHDn Aaepted By -^e�fliG / <br /> Date 12 T I fJ —t—Lr--S Area Z I Employee ID# t, S/9f <br /> sinal lnspealan By Date - ❑ SPECIAL PERMIT-Approved by <br /> :hancler of Soil to Depth of 3 FD Pit/Sump Soil Chancier: <br /> r <br /> COMMENTS <br /> ISS, PE SC ReedYed ChecldU Anmuet ParmiU <br /> Cade IN. B T ReMtted Date Service Re ues[# Invoice# Permit IM <br /> 4z.R2. 5�11 170 3"/2 00 I 5 p <br /> �2-DTAIOI _ ONSITE WASTEWATER PERMIT <br /> IJ=S)03 <br />