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9: 3 <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"°FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I (,'�� �0 !�(I CITY/ZIP <br /> CROSSSTREET ki{-}J\-}Ili UI ��1 /� Zq/� �7 <br /> J [ APN !"J/��"T(,/- -1 PARCEL SIZE I '.y� C c/ > <br /> OWNER NAME Lifl)CI IPH <br /> I�('ti I1�I 1.1 `Ii p <br /> ONE N <br /> OWNERADDRESS 7:T It.�, K10 JZ CITY/STATE/ZIP t!)_ J' %D <br /> CONTRACTOR <br /> PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE (jV, <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ LTERNATIVE <br /> 1:1 REPLACEMENT DESTRUCTION .2j CJS(.An 7 <br /> INSTALLATION WILL SERVE: LJ RESIDENCE L) COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYF,ES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ 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 /> ❑ LEACH LINES ❑ LEACHING CHAMBERS It OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ti PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE.TO NEAREST WELL It FOUNDATION ft PROPERTY LME ft <br /> ❑ SUMPS WIDTH ft LENGTH _ft DEPTH ft <br /> DISTANCE*to NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It <br /> DI.STANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE, ft <br /> I HEREBY CERTIFY THAT I 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 JOAQUIN COUNTY. <br /> MIN /'y/'�y/r�24 HOUR ADV N NOTICE;REQUIRED FOR INSPECTIONS-PLEASE.CALL(209)')53-7697 <br /> SIGNED �-C ./ �«--may <br /> TITLE DATE <br /> i t ) <br /> VU <br /> Jo o' Irl <br /> V E <br /> I I <br /> fl I <br /> DE PAR4Y�. ----—e <br /> Application Accepted Datee Area Employee. <br /> Final Inspection By Date e?/r2�y�0 ❑ SPECIAL PERMIT-Approvcd by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Char Iter <br /> COMMENTS rQ� /�{}/ w,�041 �(I j�to tk ej fAw <br /> PE SC Received Che Amount Date Permit/ <br /> Code INFO B Cash Remitted Service Request# Invoice# Permit ID# <br /> 42-02-001 <br /> 12228003 <br /> ONSITE.WASTEWATER PERMIT <br />