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31� <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE <br /> //PERMIT .},CALL 209 953.7669/�7FOR INSPECTION P1RES 1 YEAR FROM DATE ISSUED <br /> q O'7 l �t• 1 C- `•`�S6n FtJ cITYrzIP G z A <br /> JOB ADDRESS _—r_ — <br /> CROSS STREET AL, Q,3 _ APN PARCEL SIZE 2-0 j <br /> OWNER NAME r S (/On ��j{�j�'14/t PHONE 20 t I <br /> OWNER ADDRESS SC Y� i CITY/STATE/ZJP 7 p <br /> CONTRACTOR .Kyr•[�lU PHONE <br /> CONTRACTOR ADDRESS _.0 6 6C�yI,, �.o _-.__—�y/ CITY/STATFILIP yG'n'�C C✓�J 1 Cy+ /S�.7�P <br /> LICENSE QC-42 �C-36 OTHER t� NUMBER AP gs.]'T EXPIRATION DATE I 1 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> D PERC TEST # F BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION l REPAIR/ADDITION I. ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT 1 OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION <br /> FiNSALLATION WILL SERVE: ❑ RESIDENCE CDMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> R1 SEPTIC TANK TYPEIMFGf`� _ CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL 1 QomIt FOUNDATION_S , It PROPERTY LINE r ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMA O PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES -I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> FILTER BED WIDTH .30; h LENGTH �O, tt DEPTH I !K Ir It <br /> DISTANCE TO NEAREST W ELL1=fi it FOUNDATION�L�i I ft PROPERTYLINE AT ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL _, It FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE fl <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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL 209)953-7697 ? <br /> SIGNED TITLE �n�T�=Gf'hr.,.—_ DATEISY 1 1�7 <br /> ru�c; <br /> LG <br /> t <br /> t <br /> a <br /> � E T <br /> _D <br /> 013 <br /> S J AUNTY <br /> 7AL <br /> IIE MENT <br /> O PARTMENTUSEONLY _ <br /> Application Accepts ' /I, Date Area 2L)5.'L1Employee ID# )C o W <br /> Final Inspection Date L 43 ❑ SPECIAL PERMIT-Approved by <br /> Character of Sall to D h of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS xe,, -- <br /> PE SC Received heck#/ Amount Permit/ <br /> Code INFO B Cash Remitted D to Service Raguest# Invoice# Permit ID# <br /> qzl� z� 5 39 �szs— 4 20 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />