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;.30 poo/ ffous6-/6 -60a47a /tiO,� a v <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT la 00 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT - 304 E WEBER AVE-3-FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ` /J CITY/ZIP cT/nC� s� � a�✓/�� <br /> CROSS STREET `/G- APN IQ GCI D-/ PARCEL SIZE 4. 4-lL, p <br /> O <br /> /1 n <br /> OWNER NAME Al/Y'1/r�i //lJ�� PHONE r� <br /> OWNER ADDRESS CRY/STATE/ZIP <br /> CONTRACTOR .rf G r L' PHONE Cif <br /> CONTRACTOR ADDRESS / CITY/STATEIZIP I4t`1y <br /> LICENSE „]@ C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE I( <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y Nl <br /> ❑ PERC TEST # 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 ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: S NUMBER OF EMPLOYEES: '1Q <br /> SEPTIC TANK TYPF/MFG /� T.C_ CAPACITY `�D� gal #OFCOMPARTMENTS .� <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFTSTATION SIZE_ TYPEOFPUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) lhy� <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES g-;— <br /> DISTANCE TO NEAREST WELL IO/7 L ft FOUNDATION /O�-� ft PROPERTY LINE � ., fl 1 <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH_ft LENGTH ft DEPTH ft <br /> ,�✓ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> t+f SEEPAGE PITS NUMBER z WIDTH it DEPTH L4 ft <br /> DISTANCE TO NEAREST WELL �4-jJ ft FOUNDATION /(S�R PROPERTY LINE ft <br /> 1 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 /> NIININIUl1 2 OUH A 'ANCF.NOI IC-r REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED .� f� i TITLE DATE <br /> - r <br /> ad <br /> x / <br /> ti <br /> �O <br /> O N <br /> EA <br /> Z. <br /> v PARTMENT IAE ON ---- - - ---- <br /> Application Accepted B Date Area Emptt�� <br /> Final Inspection By 4 Date 7i/740 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS AA44 <br /> tCC ,oF Re-�. s9-�� <br /> PE SC Received eck#/ Amount Date Permit/ Invoice# Permit[Dp <br /> Code INFO B Remitted Service Request# <br /> N I o X10 °° it <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 1212212003 <br />