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VN0I I t VVXb I twA I LK I KLA I MLN 15Y5TEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)4663420 <br /> NON-REFUNDABLE <br /> --PnERMIT d CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS W rt �� E• I—A�l—�j0 P 9-D. cITY21P N1A-^,r-1-MA -LE-33 G y <br /> CROSS STREET `p����✓1—D -�y� APN I�O—09 PARCELSIZE c3'� <br /> � /� <br /> OWNER NAME G`1 1`'y w lly 1Ef S PHONE 4-71 <br /> —l71 — J—T!3(p <br /> OWNER ADDRESS CRY/STATE/ZIP <br /> CONTRACTOR L(✓C OAK- COE ,1V�tzZ E/✓ 6l_ PHONE 3& 03 <br /> -7!T- <br /> CONTRACTOR <br /> 7!TCONTRACTOR ADDRESS TV / &-r. CRY/STATE/LP 1-021 CJGS-,Z <br /> -40 <br /> LICENSE QC-42 QC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL O OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal *OFCOMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH It LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELLR FOUNDATION ft PROPERTY LINER <br /> ❑ SUMPS WIDTH It LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH It LENGTH It DEPTH ft <br /> DISTANCE To NEAREST WELL It FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION R PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION 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 <br /> �2A R ADVANCE NOTICE REQUIRED FOR INSPECTIONS.PLEASE CALL(209)953-7697 <br /> SIGNED / TITLE C-&7ySv&/rCN'T DATE 69 <br /> RF Y�gNT <br /> GE1VP® <br /> JUS 2019 <br /> 3 TrE EA S UI)y <br /> /1 QOp NN <br /> r <br /> 0 <br /> DEPARTME T EON <br /> Application Accepted By Date AreaEmployee ID# <br /> Final Inspection By Date 11 Sp <br /> IAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character. <br /> COMMENTS <br /> PE SC Received C Amount Date PermiU Invoice# Permit ID# <br /> Code INFO By ash Remitted Service Request# <br /> 2 I.7 W <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />