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UI101 1 C VVHJ 1 CVVH I Ct[ 1 Mr—A I IVIGIV 1 .7 TJ I LAVI VtKM1 I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA SS202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT ,� CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> .y <br /> JOB ADDRESS (LSC05 Iiti�. fryy-1A1z-D CITY/ZIP C-WrZIJ gSZc(P <br /> CROSS STREET iii N G LEy EC APN (gel - 2--2-0-0-3 3 <br /> PARCEL SIZE o <br /> OWNER NAME P-V'DY +TONT MVSSI / L-0 X\/ -+ VI CTOXIA Mu-5,S I PHONE Cool - $-'`]33 <br /> JJ'' <br /> OWNERADDRESS T3(eZ w��^�M VLLEP- CIN/STATE21P S�aLk-�l-J CA <br /> CONTRACTOR LI UL v E- �C' +�1 P1L PHONE 3(.2-1-03-7 <br /> ? <br /> CONTRACTOR ADDRESS 40-1 W' oACK CITYISTATE/ZIP uor->l CA q 6-7-40 <br /> LICENSE EIC-42 ID.0-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> �Q PERC TEST # FYUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/AODITION ❑ ENGINEER DESIGNED IALTERNATIVE <br /> ❑ REPLACEMENT 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY - 931 #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES G LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> INIMUM;4ttPUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Cc/V$UZ-rrnN"f DATE <br /> MIDDLE'.a.. p�PA <br /> PARCEL"1" - -- -s - - JO'gQUI <br /> TH DO Af COI 171 <br /> PARCEL"2" <br /> o <br /> � o n <br /> HOWARD ROAD —- SITE <br /> m wo wewv.wo.ow WING LEVEE ROAD �m m <br /> -50-:,�� VICINITY MAP <br /> _ <br /> 1111 <br /> i <br /> Application Accepted By Date 3 DEPARTMENT ySE ZNLY Z Area J �✓ 9 Employee ID# G l S <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character. <br /> COMMENTS For <br /> PE SC Received C Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By as Remitted Service Reg uest# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />