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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENV IRONMF.NTAL HEALTH DIVISION <br /> '�,JJ�JJ pp77 M/� 1�, 304 E.WEBER AVE 3RD FLOOR,STOCKTON.CA 9•" 1209)4M1RJ420 ///��� 7J/� <br /> JOB ADDRESS*` 430' 1 c-'t4w1C-y FUNDABLE PERMIT E%APNES' (gill_ D TE; PARCEL SIZE� `E V <br /> CITY/ZIP A/VT'••^oo BUILDING PERMITM/'tlP/'�`02(0Vj727–(-. Y 0 <br /> OWNERNAME.JI/[��I�('r7llA �6a6O Ir IW C "I F ADDRESS9�/��,��//[�'//� Jy��l1�n(�/V/�VE " Vb <br /> CITYJZIP SrOCV L" �, ll95�\31365 PHONE NUMBER <br /> J�� 2 4 t 3 <br /> CONTRACTOR A- wj/ S`QI •A/✓(w7NS ADDRESS <br /> CITY/ZIP `"�Kil'�i(�/R ' / F�J PHONE NUMBER 4N�/ <br /> GEOGRAPHICAL INFORMATION: COORDINATES: X Y TOWNSHIP RANGE SECTION <br /> TYPE OF SEPTIC WORK: INSTALLATION WILL SERVE: NUMBER OF LIVING UNITS: <br /> LINEW INSTALLATION ❑ RESIDENCEO ��'pyIBER 01;BEDROOMS: <br /> LIREPAIR/ADDff10N )< COMMERCIAL O � uM,DER OI+EMPLOYEES: <br /> LI DESTRUCTION ❑ OTHER <br /> ❑ ENGINEERED/ALTERNATIVE <br /> CHARACTER Oil SOIL TO DEPTH OF 3': PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH: <br /> ❑ PERC TEST(S) HOW MANY APPLICATION It <br /> X SEPTIC TANK TYPE/MFG— GVG CAPACITY I �� N OF COMPARTMENTS-2 <br /> ❑ GREASETRAP TYPE/MFG T 3 CAPACITY #OFCOMPARTMENTS <br /> ❑ PKGTX PLANT STANCE TO NEAREST: WELL <br /> PROPERTYLINE <br /> UFT STATION S PE DF PII'4w� FOUNDATION SAND OIL SEPARATOR(ENCLOSED SYSTEM) F <br /> L <br /> G J LN <br /> LEACH LINE k OF LINES: LENGTH OF LINES:—w DISTANCETONEARLIT: WELL Z FOUNDATION= PROPERTY LINE. <br /> INFLITRATOR CHAMBERS: <br /> ❑ FILTER BED WIDTH LENGTH DEPTH DIATANCETONEARVOU WELL FOUNDATION PROPERTY LINE <br /> ❑ MOUNDED WIDTH LENGTH DEPTH DINTANCE TO NEAREST: WFLI. I'OUNDATION PROPLRTY LINE <br /> ❑ SUMPS WIDTH LENGTH DEPTH_ OISTANCETONEAREST: WELL FOUNDATION PROPERTY LINE _ <br /> ❑ DISPOSAL PONDS WIDTH LENGTH DEPTH DLNTARCETONEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑ SEEPAGE PITS M DIAMETER DEPTH OISTANCETONEARENT: WELL FOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS <br /> AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> 'M/,'NN M NI M�2�1HOU R ADVANCE NOTICE REQUIRED FOR INSPECTIONSVL C CA 9)468-3423 q A <br /> SIGNED: 0= JU LIIO TITLE DATEA0 O <br /> —_ _ <br /> __ ___ — _ <br /> _ _—_—po cm <br /> _1 140 <br /> A 7 7 7— ## <br /> APPLICAT p ! C'n ' `�'�`q'S ^•,nDATE.•O1 O// /L -AREAEEMMPPPLLLOOOYEE ID# TRI LOCATIOY_/ <br /> INSPECf _ �JGG1# DAT �� 7—'PERMIT TIN YES DATE: I OR: •-'_.•_ <br /> � //ff <br /> COMMENTS: - .J•T -? � <br /> —was aff� <br /> F-2771 (e) <br /> SC INFO MOUNT CHECKv ASH RECEIVED ATE PERMIT/SERVICE REQUESTa :tLVOICEv SEPTIC IDv <br /> REMITTED BY <br /> 25b 35 ��s j z-z- '° o �n3/yr <br /> :tea 36 X A&dLeX, <br /> REVISED F1.441 �� i �<IC 17,7 �' <br />