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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE-3""FL-STOCKTON CA 9' (209)468-3420 <br /> —ON-REFUNDABLE PERMIT / CALL(26VrO53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRWDATE ISSUED <br /> JOB ADDRESS ��%t/�� 1'V �F7/1hYJT (� CITY/ZIP N <br /> 2OSSSTREET �.9�inw�' �.L APN �(/ 1-17f1-7� PARCEL SIZE D <br /> °o <br /> `WNER NAME I�/7G/l/"n//� /G/7Zl}t21 PHONE <br /> OWNER ADDRESS �(fl lX_ CI S�fy ��,1,_� CITY/STATE/ZIP <br /> JNTRACTOR �CM �1,O��c/ J�Y/�L PHONNE <br /> TUNTRACTOR ADDRESSi��/C� �� //.'l.C''�'c' //J.,!/� CITY/STATE/ZIP lr;r <br /> LICENSE GLC-42 ❑C-36 OTHER NUMBER EXPIRATION DATE G <br /> ATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> 1 PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION AK REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> IISTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> r NUMBER OF LIVING UNITS: J // NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG lXi Sfr wA CAPACITY gal #OFCOMPARTMENTS Z <br /> -11 GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> I PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION fl PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> i <br /> L LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES �G ft <br /> DISTANCE TO NEAREST WELLcT ft FOUNDATION fl PROPERTY LINE_ 755 fl <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> I MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> _ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ sumps WIDTH ft LENGTH fl DEPTH ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I DISPOSAL PONDS WIDTH fl LENGTH ft DEPTH ft <br /> _ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> SEEPAGE PITS WIDTH �� fl LENGTH ft DEPTH i�J , ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ZjZ ft PROPERTY LINE <br /> 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> 'GNED TITLE DATE G3 <br /> a. <br /> car <br /> Fol I <br /> y )1 <br /> l� <br /> S oat) avl Es oN <br /> UB c TALHE <br /> or <br /> w <br /> L(/ <br /> �. DEPARTMENT USE(,.ONLY 41/411 <br /> Application Accepted By 'J-w Date I Area 2 Z Employee ID# <br /> -inal Inspection By Date a3/3 ❑ SPEC 2kL/PERMIT-Approved by <br /> haracter of Soil W jh of 3 <br /> pt "Ft: . .,z- _ Pit/Sump �f7"ri-i Sump Soil Character: x-.,-- <br /> ­iE,OMMENTS <� 'i- 3', �� _ �T y _ .fir/ -{ <br /> %f^W {- c'�`• "/ ��:� r„-r i;7'J -!-/, `E- Cti�� �C.:iyt�./>ir�r,1'cx ir,.+,,. 7..�r_t--- <br /> PE SC Received -"Che Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO BI ' <br /> yash Remitted Service Request# <br /> 2 - 6 s ULy3 <br /> se-01.001 1 <br /> 1 <br />