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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> 4 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE-Y'PC-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 9$3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS �J A 9 CITY/ZIP�/ In <br /> CROSS STREET ✓ APN C PARCEL SIZE .134LF.3 p <br /> / a <br /> OWNERNAME PNONe <br /> OWNER ADDRESS sc-cz CITY/STATEJZIPRM/ vcw <br /> I <br /> CONTRACTORPHONE <br /> CONTRACTORADDRESE - CITV/STATEIZIP gnykm <br /> LICENSE 0 C4 LI C-36 OTHER NUMBER E%PIRATIONDATE <br /> WATERTABLEDEPTH: ft GEOGRAPHICAL INFORMATION: CoordbutUS X Y <br /> ❑ PERCTEST # PING PERMIT# LANDUSE LICATIONN <br /> TYPE OF WORK: O New INSTALLAION REPAIR/ADDUI N -❑ ENGINEER DESIGNEDfALTERNATIVe <br /> ❑ REPLACEMENT D N - <br /> INSTALLATION,WILL SERVE: CI RESIDENCE LJ COMMERCIAL x <br /> NUMB ER OF LIVING UNITS: NUMBEROF BEDROOMS: <br /> ❑ SEPTIC TANK TYPE/MPG CAPACD Permft MW hart$ mdW <br /> ❑ CREASE TRAP TYPE/MFG CAPAC1by <br /> ork hem ngs@ompf ft&U [n I <br /> ❑ PKC TX PLANT DISlANCETO NEAREST: WELL R FOUNDATI "D P ITTCOILII <br /> , it i <br /> OIDI J <br /> ❑ UFTSTATION Sin TYPE OF Pump SAND OIL SEPARATOR(ENGLOSEDS M) <br /> \ <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OFLINES LENGTH OF LINES it <br /> DISTANCETONEAREST WELL A FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH R LENGTH ft G DEPTH it 1 <br /> DISTANCETONFARRBT WELL R FOUNDATION it PROPERTY LINE H <br /> Q <br /> ❑ MOUNDED WIo'rx it LENGTH fl DEPTH ft � <br /> DISTANCE TO NEAREST WELL it FOUNDATION B PROPERTY LINE It L3 <br /> ❑ SUMPS Wwrti ft LENGTH ft DEPTH it <br /> DISTANCE TO NEARIST WELL A FOUNDATION it PROPERTY LINE A <br /> ❑ DISPOSAL PONDS WIDTH H LENGTH It DEPTH ft <br /> DISTANCETONFARFST WELL fl FOUNDATION it PROPERTY LINE it <br /> ❑ SEEPAGE PITS NUMBCR WmTH it DEPTH D C <br /> DISTANCETONEAREBT WELL it FOUNDATION It PROPERTY LINE B <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> d ORDINANCES,S TL LA WE NO RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. - <br /> TIU, HO ANCE NOTICE REQUIRED FOR INSPE ONS-PLEASE CAQL(209)9$3-7697 <br /> �i t <br /> SIGNED ' TITLE BATE � I <br /> N <br /> 44a L <br /> SON' Qi, arrj <br /> DEPARTMENT. E-ONLY— <br /> Application <br /> .,..�..�..-.� _ <br /> Application AeteFood BYnot< O( Arca Employee[D# rf-s /4q l <br /> Fin.]lvpecfbn By Date ❑ SPECIAL PERMIT-Approved by i <br /> Cha aemr of Soil to Depth of 3 Ft: PIDSump Soil Character: <br /> COM EN S S OC-S- vtC -CL 4)/ p <br /> • !Y rirl IR- cJ, v.sL.9 <br /> PE SC Received Ch.U/ Amount ate erml Inv ce ermit ID# <br /> F42..z41 <br /> ode INFO B u Remitted ServiceR umt# <br /> ms �I o0 oa �� kDc 83 3 <br />