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9'3d c�3c/�3S <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERK& <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE-3"FL-STOCKTON CA 95202-(209)4693420 <br /> NON-REFUNDABLE PERMIT I ^ CALL(209)953-7697 FOR INSPECTIONS EXPIRES YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 01.8a O a �.� "yAmA QO�.I� CITY/ZIP 2 /t I 9 <br /> CROSSSTREET _;1 2/"e A..' APN <br /> Y'0// -0 <br /> O ..J PARCELSIZE Ll,21' <br /> 11 e <br /> OWNERNAME pr„" D L%SA 541.�G-��ui�Z PHONE ' <br /> OWNER ADDRESS CITY/STATE/ZIPl_D4J.�� <br /> CONTRACTOR PHONE (909)%0--2327 <br /> CONTRACTOR ADDRESS 71 0 E- od'=el t/eog CITY/STATE/ZIP \ <br /> LICENSE C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X y f <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: g NEWINSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEERDESIGNEp/ALTERNATIVE <br /> ❑ REPLACEMENT Cl DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: .'i., NUMBER OF BEDROOMS: NUMBEROFEMPLOYEES: �. <br /> SL SEPTIC TANK TYPE/MFG **0Nej-A_kI/ '0j L CAPACITY gal #OF COMPARTMENTS <br /> /❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL /. '7 C] ft FOUNDATION ft PROPERTY LINE _ <br /> ❑ LIFT STATION SIzE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) f: <br /> t <br /> y, s <br /> Jai LEACH LINES ❑ LEACHING CHAMBERS #OF LINES_._ LENGTH OF LINES el ft <br /> / DISTANCE TO NEAREST WELL ft FOUNDATION, ft PROPERTY LINE���_R <br /> ❑ FILTER BED WIDTH ft LENGTH �T R DEPTH ft <br /> DISTANCE TO NEAREST WELL /70 It FOUNDATION VO 1 ft PROPERTY LINE (AI91 ft <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <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 /> SEEPAGE PITS WIDTH 31 <br /> ft LENGTH �j ' ft DEPTH 'J oLk ft <br /> 1111"`` DISTANCE TO NEAREST WELL it FOUNDATION Sf0 It PROPERTY LINE (!D 1^ :ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION 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 /> NIMUA` UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED r TITLE_ 4� DATE <br /> I <br /> DEPARTMENT U E 9NLY <br /> Application Accepted By Area _ Employee ID# _ �/y <br /> Final Inspection ddeDate 43 11SPECIAL PERMIT-Approved by <br /> Character of S epth Ft: PIUSump Soil Character: <br /> COMMENTS,,,-/'e <br /> PE SC Received Checkw Amount Date Permit/ Invoice# Permit[D# <br /> Code INFO B Cash Remitted Service Request# <br /> fi zo- 1 L*D3 <br /> 42.01-001 <br /> 12/2/02 ONSITE WASTEWATER PERMIT <br />