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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> 'SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE-3`°FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT <br /> CALL(209)953-7697 FOR INSPECTIONS EXPIRES <br /> rI.,YEAR FROM DATE ISSUED <br /> JDBADDRESS l/ E. 14i V T CITYIZIP T�v`f+'T- _ LA <br /> CROSSSTRELT �/JAPN I-S7- .S +P7ARCELSIZE GO--5'7 flirt 0 <br /> OWNERN4ME DKRA L /q'�A eEF-- PHONE 4D��'`�Z� <br /> OWNER ADDRESS T G-�o�C !-1 Z i CITY/STATE/ZIP IR)u- '`�+ 5-1 <br /> • • / <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C42 0C-36 OTHER NUMBER UPI RATION DATE_ —� <br /> WATER TABLE DEPTH: A GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST tl BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE Of WORK- ❑ NEW INSTALLATION ❑ REPAIR)ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT �. DESTRUCTION t?.•x r_S lir• L . <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER , <br /> NUMBER OF LIVING UNITS: NUMBEROPREDRODMS: NUMSF' FEMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/W(FG_ CAPACITYI—PARTMENTS MPARTMENTS <br /> LI GREASE TRAP TYPEIMFG CAPAC gal` !it`OI <br /> ❑ PKG TX PLANT DISTANCETONEAREST: WELLR • NDATION \\- ROPERTY LINE ft <br /> O LIFT STATION SIZE TYPE OF PUMP _ O SA.ND� PARATOR(ENCLOSED SMEM) <br /> ❑ LEACH LINES ❑ LE ACHING CHAMBERS #OF'L S LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL R F NDATION ft PROPERTY LINE ft <br /> E) FILTER BED WIDTH ft LENGTH � DEPTH A <br /> c <br /> DISTANCE TO NEAREST WELL- ft FOUNDATIO R PROPERTY LINE ft <br /> LI MOUNDED WIDTH R LENGTH DEPTH ft <br /> DISTANCE TO NEAREST WELL_ 7ro1ATQN <br /> R PROPERTY LINE <br /> ❑ SUMPS WIDTH R LENGTH R DEPTH R II I <br /> DISTANCE TO NEAREST WELL ft PROPERTY LI%E❑ DISPOSAL PONDS WIDTx R L NGTN ft DEPTHDISTANCE TO NEAREST WELL R PROPERTY LIME❑ SEEPAGE PITS NUMBER WIDTH ft DEPTHDISTANCE TO NEAREST WELL R PROPERTY LINE R <br /> I HEREBY CERTIFY THAT IHAV R PARED THISAPPL TIONA. THE WORK WILL HE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> 1 .CES,STATE LAWS AND � D REGULATIONS OF SAN JOAQUIN COUNTY, <br /> 1 OUR wDVANCE NOTICE REQ IRED FOR INSPECTIONS-PLEASE CALL(?ll9)957-7697 r <br /> SIGNED Ti T..: tSZ•!J �r� --- <br /> r J <br /> t ! <br /> 1 1 <br /> ^��fy•Ay. <br /> 2L 12. <br /> Application Accepted By _�./ •� �' - Date �'' /F C Area '�-�r Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by_ <br /> Character of Sail to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS H toCQ4-e eA 4 d4e s <br /> PE SC Received bee Amount pate Invoice III PermitlD# <br /> Code INFO B �r�mash Remined �" Service Requeest# <br /> 47-ZI 6-7S W cS' .n I> (1 p 1 Yl-m l <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> mmn= <br />