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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-REFUNDABK fEAMIT nCALI, 209 953-7697 POR IN'SPEC'TIONS EXPIRES 1 YEAR Figgim DATE ISSUED <br /> JOB ADDRESSe, CITY/ZIP N <br /> fes/"�,, /� �J�J, //1� -i <br /> CROSS STREET rear/1 V � APN I /`-J-OZ-� PARCEL SIZE o <br /> O <br /> 7 A <br /> OWNER NAME /`�,'PPHHHO�NE�. �//'./��M ' <br /> J4 CA459�� <br /> OWNER ADDRESS 56.� A t,7�+ClTY/STATE/ZIP 1 +b1--4- �,�.V�(�,/J�I- j —�/7 <br /> CONTRACTOR 'lam - 1 V l.� PHONE�\L�-� / <br /> lit <br /> CONTRACTOR ADDRESS Ai Of lkltLCITY/STATE/ZIP sit q!E <br /> I I An 15 <br /> LICENSEC-42 L3 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICALINFORMATION: Coordinates X Y <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 w` <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: I" <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPFJMFG CAPACITY gal #OF COMPARTMENTS 17) <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> �❑I LIFT STATION SIZE- TYPE OOFF�P;UyMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) n/� <br /> C1 LEACH LINES � LEACHING CHAMBERS V'Z.i' -36 _ #OF LINES LENGTH OF LINES .��y�ft (bJ J <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 fl FOUNDATION ft PROPERTY LINE ft i <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST <br /> •//t WELL fl FOUNDATION ft PROPERTY LINE_-�7-•A/-ft <br /> SUMPS WIDTII L.- ft LE GT ft DEPTH .r1_(+�- ft <br /> DISTANCE TO NEAREST WELL I _}_ft FOUNDATION *4 ft PROPERTY LINE S"_ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> ❑ SEEPAGE PITS NuMBER WIDTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> CaW' ORDDIINANCES,STATE LAWS AND RULES AND REGULATIONS OP SAN JOAQUIN COUNTY. <br /> SIGNEII JUM 2{fJ 3 IT :REQUIRED F TITLE P. l(V,-Pl G "09)953 T07 <br /> DATE ' I65 <br /> I. <br /> ,V -11 �-1 I t <br /> J <br /> n <br /> S <br /> O <br /> 1 <br /> 7 n N <br /> � MNT <br /> T D <br /> DEPA M . l E 0 LY <br /> Application Accepted By Dale 6 Area 2- Employee IDN <br /> Final Inspection By _ J Date 1 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Dept of 3 Ft: Pit/Sump Sol]Character: <br /> COMMENTS <br /> PE SC Received hec Amount D to Permit/ Iavolce# Permit ID# <br /> Code INFO B .ash Remitted Service Request# <br /> YLIA, I! i2CYJ 3 03 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/222003 <br />