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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT gT �� <br /> NAN JOAQUIN COI'NTY'ENVIRONMENTAL HEALTH DEPARTMENT3D4 F WEBER AVE-3"FL-ST'OCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-76,97 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> JOB ADDRESS / K� CRY/ZIP et9� _q <br /> CROSSS:REST APN wQ� -O[� //!D -0 PARCEL SIZE ( `_ <br /> OWNERNAME 17J 1�(i� TQ•LI�� ,` IBJ P- L/3V ��4� PHONE ✓ /4 <br /> OWNER ADDRESS � 'L' CITY/STATFIZIP <br /> CONTRACTOR PHONE <br /> v_SII <br /> CONTRACTURADDRESST 2160 <br /> ✓� /� CLTV/STATE/ZIP <br /> LICENSE <br /> (?<'42 ❑C-36 OTHER NCMBER q 7?-Z � EXPIRATION DATE <br /> WATER TABLE DEPTH:_ LC.b l � fl CYOCRAPHICAL INFORMATION: Coordinate$ X V_ <br /> FQ_­PERC TEST(S) NUMBER LAND LISE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIRfADDrnori O ENCINEERDMIGN'ED/ALTERNATIVE <br /> O REPLACEMENT D DESTRUCTION r <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ErOTHER PeS+ A✓ Q1 <br /> NUMBER OF LIVING UNIT'S: NUJMyBBER OF IREDROl7MS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG TC'-T �4� CAPACITY 1�-�a _ gal N OF COMPARTMENTS 1 a <br /> ❑ GREASE TRAP rYPF/MFG CAPACITY gal #OF COMPARTMENTS__ t <br /> ❑ PKC TX PLANT DISTANCE TO NEARGPT: WELL ft FOUNDATION R PROPERTY LINEc�2dO ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACH ING CHAMBERS 4OFLINES C�D^-_ LENGIH OFLINrs <br /> DISTANCE TO NEAREST Wt!.L��' ft FOUNDATION yc,• -ft PROPERTY LINE / H Q <br /> ❑ FILTER BED WIUTn _ R LENGTH fI1 DEPTH R 0. <br /> DISTANCE TO NEAREST WELL_ ft FOUNDATION ft PROPERTY LINE H <br /> ❑ MOUNDED WLDTH_ it LENGTH _fl DEPTH II <br /> DISTANCE TO NEAREST WELL ft FOUNDATION_ ft PROPERTY LINE H <br /> (3 SUMPS WIDTH it LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL _fl FOUNDATION_ ll PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH _A LENGTH _ it DEPTH (t <br /> DISTANCE+T�O NEAREST WELL. ft FOUNDATION ft PROrER1Y�LINE A <br /> SEEPAGE PITS WIDTH �r0ft UNGTH H fl <br /> DEPTH p-_S J <br /> DISTANCE TO NEAREST WELL�S� It FOUNDATION Ye R PROPERTY LINE_ fl <br /> 1 HEREBY CERTIPY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK.WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATED AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MI'I M ADVA ICE REQUIRED FOR!NS►E.TIONS-PLEASE CALL(209)953-7697 g <br /> SIGNED TITLE DATE <br /> Or <br /> r <br /> ze <br /> V <br /> 16 00 <br /> d) <br /> 80 NL LTi SE C <br /> DEPARTME/N'T USE O <br /> r Applicatlon Accepte� _ 1N4/��/ Dale M - "Q', Arca _ P.mpinyee lD#_ <br /> Final Inepectlon IDate o 7 [3SPECI V PERMIT-Approved by _ <br /> Character of Sob to Depth of Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE Sc Received Mee Amount Permit <br /> Code INTO Cash Remitted Yale Service Rectarst# Invoice# PermfllD# <br /> Z.I 0.7 - � '310 003 S 4 Z3 <br /> 42-01-001 <br /> zzro2 ONSITE WASTEWATER PERMIT <br />