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viTvaau r•cavaur aa.a. aa.a.�a.. .aa <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT aL 304E WEBER AVE-3"PL-STOCKTO,CA 95202 - (209)06#-3920 ' <br /> NON-REFUNDABLE PERMIT CALL 2 -7697 FOR INSPECTIONS EXPIRES 1 YEAR FRC TE ISSUED <br /> TJosADDRESZ l l l CITY/ZIP r <br /> / I <br /> CROSS STREET !-1 l L/LVrI✓ y APN` `.Y- :i{'EJ'(- 7 PARCEL SIZE <br /> 1 11 yO <br /> OWNER NAME +� Lq { Y .:I A C ' i .. <`� . \ PHONE 'b <br /> 1 5°i <br /> T O"ER ADPRELSS j 'I CITY/STATE/ZIP ti I . 1 F D `l y Z <br /> CONTRACTOR 'A PHONE <br /> `CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATERTABLEDEPTH: R GEOGHAPHICALINFORMATION: Coordtnr4r X Y <br /> ❑ PERC TEST # BUILDINGPERMIT# LAND USE APPLICATION# <br /> boo TYPE OF WORK: ❑ NEWINSTALWTION ❑ REPAIRIADDITION ❑ ENGMSERDESIGNED/ALTEHNATmE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RPSIDENCL ❑ COMMERCIAL ❑ OTHER <br /> NUMBEROFLIVINGUKIIS: NUMBER OF BEDROOMS: NUMBEROPEMPLOVEES: <br /> `❑ SEPTIC TANK TYFwMFG CAPACITY Eel #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY Sol #OF COMPARTMENTS <br /> ❑ PEG TX PLANT DISTANCEMNEARFbT: WELL B FOUNDATION it PROPERTY LINE ft <br /> �❑ LIFT STATION SIZE TYPEOPPUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS koP LINES LENGTH of LINES; it <br /> DISTANCE M NEAREST WELL it FOUNDATION B PROPERTY LINE R <br /> ❑ FILTER BED WIDTH B LENGTH ft DEPTH it S <br /> DISTANCEMNEABLIT WELL ft FOUNDATION ft PROPERTY LINE it <br /> ❑ MOUNDED WIDTH it LENGTH ft DEPTH it <br /> DISTANCEMNEARESI WELL R FOUNDATION R PROPERTY LINE it <br /> `❑ SUMPS WmTx R LENGTH it DEPTH it <br /> DISTANCETONEARESr WELL ft FOUNDATION it PROPERTY LINE it - <br /> ❑ DISPOSAL PONDS WIDTH it LENGTH it DEPTH it t <br /> DISTANCEMNEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Y❑ SEEPAGE PITS Summit WIDTH ft DEPTH R T) <br /> DISTANCE TO NEAREST' WELL ft FOUNDATION ft PROPERTYLgE R <br /> f <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQVIN COUNTY. <br /> 1 MINIMUM to HOUR ADN'ANCE NOTICE REQUI RED FOR I INSPECTIONS-PLEASE CALL(209)453-7697 <br /> SIGNED Fv K--- TITLE DATE <br /> I � <br /> J <br /> i <br /> I <br /> O <br /> � L \ <br /> 1 J <br /> I i <br /> — DEPARTMENT LS ONLY <br /> Application Accepted By }+-�— Date 2 4f I S ATee /L/ Employee ID# <br /> Float Impectlon By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PidSump Soil Chencter: <br /> COMMENTS <br /> r <br /> 70 SC Received Amount Rafe Permltl IDvoim# Permit lD# <br /> Code Ingo , Cnh emitted SeMceR Deet# <br /> .. 7z-n z / )f.I,:.i' "r G.w •/ -5•J <<G✓ 411� iJ <br /> R-02-901 ONSITE WASTEWATER PERMIT <br /> v 12RJ20D3 <br />