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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTDN CA 95202-(209)4663420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED <br /> JoBADDRESS °1010 W, ftDWA(LD !ZD CnYZP S7yck-T-OtN1 9S7-OIo <br /> CROSS STREET U N D/N t APN 100y-190-oLL ♦ 3�� Al <br /> �L.I ,A{ yLA��ar/r �y M w A _ PARCELSOE <br /> • OWNER NAME A-01- FAizm> CMnR C. MIS P•-C4i/ /IPHONE. <br /> OWNERADDREB6 SA MG CRFRI <br /> Y/STAIP <br /> CONTRACTOR LIVE `At-W- <br /> � �#J�� <br /> � C,0CNV1TAL PHONE 3(09- 03 <br /> CTOOAK-5-r. <br /> CONTRARADOREW Y-0-T W . OAIL 5-r' C"STATEZP LO D II 0A <br /> LICENSE QC42 p"S OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPT: R GEOORAPHICALINFORMATION: CiNrdinate5 X <br /> y/ Y <br /> h` PERC TEST # BUILDING PERMM# USE APPLICATION# <br /> TYPE OF WORK: O NEW INSraL,j p REPANUADDITION <br /> ❑ REPLACEMENT 0 ENGINEER DESIGNED/AITERNgTryE <br /> ❑ DESTItULTON <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIANG UNIT NUMBEROFBEDROOMB: <br /> NUMBER OF EMPLOYEEB: <br /> ❑ SEPTIC TANK TYPNMFG CAPACITY <br /> ❑ GREASETRAPgal #OFCOMPPRTMENTS <br /> TTPE/MFG CAPACITY gal #OFCOMPARTMENT$ <br /> DISTANCETONEAREST: WELL ft FOUNDATION R PROPERTYLINE R <br /> ❑ UFTSTATION SIZE TYPE OF PUMP O PKGTXPLANT O SAND OILSEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ L.EACHINGCHAMBERS #OFUNEs <br /> LENGTH OF LINES It <br /> OISTANCETONEAREST WELL R FOUNDATION <br /> ❑ FILTER BED WIDTH R PROPERTY LINE R <br /> R LENGnI ft DEPTH R <br /> C3 MOUNDED DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY R <br /> WIDTH R LENGTH R DEPTH <br /> DISTANCE TO NEAREST R <br /> 13 SUMP$ R FOUNDATION R PROPERTY LINE ft <br /> WIDTH R It LENGTH R DEPTH <br /> DISTANGETO NEAREST R <br /> WELL fl FOUNDATION R PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH k LENGTH R DEPTH <br /> DIBTMCE TO NEARBST k <br /> WELL R FOUNDATION R PROPERTYLWE R <br /> O SEEPAGE PITS NuxeEa WON <br /> k DEP H It <br /> DISTANCE]#NEAREST WELL R FOUNDATION R PROPERTY LINE <br /> R <br /> 1 HEREBY CERTIFY THAT HAVE PREPAREDTHISAWSANDRUAND THE WORK WILL BE DONE IN ACCORDANCEWITH SAN JOAQUIN COUNTY ORDINANCES, <br /> • A STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> �MUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-769] <br /> SIGNED ��/,/�/tel,/r��/C� TIRE (,O/JSVL-7�11V"1• <br /> DATE 1 -13-IS <br /> A <br /> OCT,2 O <br /> - -��:,--fir-^r^_ � � n. —' — _.+� - AIV 6�20 <br /> Jp 15 <br /> NgOU/V <br /> NCO <br /> I <br /> TNOE A/ITM•q�N'y <br /> I � =za - <br /> QQ � DEPARTMENT USE ONLY r�� <br /> Application Accepted By�]{�.1.all Data Area V IC�Gj Employee lD#L I.A I <br /> Final Inspection By �1T Date ❑ SPE—CI-AyL P�'ERM—R- <br /> Charaeter of Soil to Depth of 3 Ft: ApPmvatl by <br /> COMMENTS Pit(Sump Soil Character: <br /> PE SC Received Che Amount Permit' <br /> Code INFO B ash Remittetl Date Invoice# Permit ID# <br /> Lf 222 rJZ $Z O Service Re uest# rm <br /> � � L <br /> • <br /> A2-0t <br /> 10/MOT ONSITE WASTEWATER TRT%I ]SYSTEM PERMR <br />