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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> /a 9° <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3-FL-STOCKTON CA 95202 .(209)16&3110 <br /> NON-REFUNDABLE PERMIT CALL 209 957-7697 FOR INSPECTIONS EXP RESLI YEAR FROM DATE ISSUED <br /> Joe ADDRESS ! 3 East- tate Rohe. 17 CMIZIP 1 y <br /> /� <br /> A-, <br /> CROISSFREET 1T)tw LAnc APN M— 120—N� PARCELSIEE -U IHC en <br /> OWNERNAME T IO+II1 4 immW Truck,Iv1U,I PHONE /1/� (�/-��/� �2 <br /> OWNER ADDRESS r CITY/STATE/TJP fJ(T)., t N -I�LsC^fTl <br /> COMPACTOR Mol 0. T PHONE — - <br /> CON mACTORADDRESS O CrrYTBrATFIZIP <br /> LICENSE 13 C42 ❑C-3G OTHER NUMBER EEPIRATION DATC <br /> WATER TABLE DEM: R CEOGMPHICAL INFORMATION: COONIBIIel X Y <br /> PERC'fE57 # BUILDINGPERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED IALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATIONWILL SERVE: El RESIDENCE ❑ COMMERCIAL ❑ OTHER !N <br /> NUMBER OE LIVINGUNM: NUMBEROFBEDROOMS: NUMBEROFEMPLOYEFS: W <br /> ❑ SEPTIC TANK TYPEIMEG CAPACITY Sal #OFCOMPARTMENTS <br /> ❑ CREASE TRAP TYPE/MFG CAPACITY gal #OFCOMPARTMENT9 <br /> ❑ PKC TX PLANT DIWANCETONEABEET: WELL R FOUNDATION It PRO ry LME R O <br /> ❑ LIFT STATION SEES TYP6OPPUMr ❑ SAND OIL SEPARATOR(ENCLOBEDSYWEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OFLINES LENGTH Of LINES ft <br /> DISTANCETONEAREST WELL R FOUNDATION R PROPERTY LINE fl <br /> ❑ FILTER BED WIDTH ft LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LME fl <br /> O MOUNDED WmIN ft L.EeGTH R DEPTH fl <br /> DISTANCETONEAREST WELL fl FOUNDATION R PROPERTY LINE it <br /> ❑ SUMPS WIDTH fl LENGTH fl DEPTH fl <br /> DISTANCETONEAREST WELL R FOUNDATION ft PROPERTY LINE fl <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH It DEPTH R <br /> DISTANCETONEAREST WELL fl FOUNDATION R PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH it DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WM SAN JOAQUIN COUNTY <br /> ORDINANCES STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> M M M24 HOUR ADVANCE NOTICE REQUIRED FOR INS^CILEAy0951-7697 <br /> SIGN D CALL ) <br /> DATE <br /> F ( X� <br /> O O IN cc JN <br /> DEPARTMENT USE NLV 0 53�ry <br /> Applkatlon AseplM BY D Z 4 Area Employs IDk <br /> Find Inspection BY Dale ❑ SPECIAL PERMIT-Appmvedby <br /> Chnracteref Sell W Dept hFt: Pit/Sump Soil Ch..l.r. <br /> COMMENTS p <br /> h>, 4 �YI�L GCGPI <br /> PE SC Received s AlRonnt ale PermlU Invoice# Permit IDM <br /> Cade INFO <br /> B' <br /> Remitted Servl <br /> �-L p <br /> --------------- <br />