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lop <br /> ONSITE WASTEWATER TREATMENT SYSTEM-VERate 303id; <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WERERAVE-3Y°FI,-SrOCKTON CA 95202 -(209)463-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 11141n1 S oD:J.aa IBJ f. Cm/ZIP o'noADo <br /> bate CHOSE STREETFT�`✓l.�Y G�(e�-.�nJO 1� APNL'— 'a8—I PARCELSrU <br /> /' o <br /> OWNERNAME LTO se ' PRrrkr� PHONE <br /> OWNERADDRES.S 11Lfp T6 Lndp,;�. nt CITY/STATE/LIP wlpMVa ef- f :.4 l^S2 Tf <br /> I' �/� <br /> CONTRALI'OR �_ -101 YC.IC�1a'C .�Cfl/J Gr PHONE <br /> B� <br /> CONTRACTORADDRESSA� � Xi 1, n CITY/SFATEJZIP yY�pn/iGt:A i N^M' "It-39& <br /> LICENSE LI C42 ❑C-36 OTHER NUMBER E%PIRATIONDATE 6O <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> a� ❑ PERCTEST(S) NUMBER LAND USE APPLICATION III <br /> TYPE OF WORK: NEWINSTALLATION ❑ REPAHUADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE N <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIALO ❑ OTHER <br /> ` NUMBER OF LIVING UNITS: L NUMBER OF BEDROOMS: �l NUMBER OF EMPLOYEES: <br /> SEPTICTANK TYPEIMFO P9 L CAPACITY 6b gal MOFCOMPARTMENTS.Z <br /> ❑ GREASETRAP TYPF/MFG CAPACITY gni MOF COMPARTMENTS <br /> Via ❑ PKGTXPLANT DISTANCETONEAREST: WELL (OO( fl FOUNDATION l ft PROPERTY LINE 7T\T it C' <br /> ❑ LILIFTSTATION SIZE TYPEOFPUMe ❑ SAND OIL SEPARATOR(ENCLOSEDSmem) �) <br /> W' LEACH LINES ❑ LEACHING CHAMBERS B OF LINES LENGTH OF LINES_ (5ft <br /> ` DISTANCETONEAREST WELL II�O'F' H FOUNDATION LSI fl PROPERTY LINE �l 0 <br /> ❑ FILTER BED WIDTH fl LENGTH It DEPTH fl <br /> DISTANCETONEAREST WELL fl FOUNDATION ft PROPERTY LINE fl <br /> ti ❑ MOUNDED WIDTH D LENGTH ft DEPTH ft <br /> ,,,� <br /> .SO'er DISTANCETONEAREJ�EST7 WELL ft FOUNDATION ft PROPERTY LINE R <br /> Q UMPS WIDTH fl LENGTH L 4! It DEPTH IC)J ft <br /> DISTANCETONEAREST WELL `, !�-nll_ft FOUNDATION / It PROPERTYUNE BOJ fl <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH fl DEPTH ft <br /> haI DISTANCETONEAREST WELL ft FOUNDATION_11 PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LUNE ft <br /> V• 1 HEREBY CERTIFY THAT 1 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 /> MI�NIJMUM 24HJ RADVANCE NOTICE REQUIRED FOR INSPECTIOONS�-PLEASE CALL(209)9534697 <br /> SIGNED Ll/CT. TITLE WIrIT CC�rS� TE 6� 1 D Q� <br /> f <br /> Ix I <br /> No 11 'le <br /> S <br /> E <br /> JO O I <br /> BIB <br /> DEPARTMENT USE ONLY p <br /> Application Accepted BY C Date /�—/C>'-R%/� Area 2/ Emp1OY<e IDM 0��O <br /> Final lnspa139n By DRte ❑ SPECIAL PERMIT-Approved by <br /> ` Character of Sollln eplh SIJIVSum�p So Ctiara ler: - <br /> COMMENTS <br /> r EFs,✓ C;t.,r W <br /> `a PE SC Received Amauat ate Permit/ Invoice0 Permit lDN <br /> Code ISro B CaR Remitted Service Banned# <br /> that <br /> .]-01-001 <br /> IMM2 ONSITE WASTEWATER PERMIT <br />