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.3. <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALITH DEPARTMENT 304 E WEBER AVE -3- Fl, -STOCKTON CA 95202 - (209) 465-3420 <br />NON-REFUNDABLE PERMIT 3 t CALL 209 953 -7697 -FOR INSPECTIONS' "' EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS �7 s � 17 �/ CITY/ZIP <br />17 h J I J^ 3 3 0 <br />q <br />CROSS STREET M el % y APN ` / 19 PARCEL SIZE � 4G , <br />/CI , <br />of ^.5-14Z )wdr1 <br />OWNERNAME t)/f Nr,,.jj FQdA4�y—( <br />PHONE <br />_ as �p IY <br />OWNER ADDRESS 3 W 7 ��0 I`�• CITY/STATE/ZIP <br />• /�A <br />�7' 9S33O- <br />CONTRACTOR <br />PHONE �o -S I62 <br />CONTRACTOR ADDRESS CrrY/STATE/ZIP <br />I <br />LICENSE ❑ C-42 ❑ C-36 OTHERNUMBER <br />EXPIRATION DATE <br />WATER TABLE DEPTH: 9 ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />❑ PERC TEST # BUILDING PERMIT # y 2—LAND USE APPLICATION # <br />TYPE OF WORK: Cir NEW INSTALLATION ❑ REPAIR/ADDITION <br />❑ ENGINEER DESIGNED/ALTERNATIVE <br />. •. ❑ REPLACEMENT - 1 ,.. ❑ DESTRUCTION <br />.. - .. <br />INSTALLATION WILL SERVE: j ESIDENCE ❑ COMMERCIAL <br />❑ OTHER <br />NUMBEROFLIVING UNITS: �'. NUMBER OF BEDROOMS: <br />y. <br />NUMBER OF EMPLOYEES: <br />�•—e <br />-r—f, <br />SEPTIC TANK •; TYPE/MFG 1 :OD CAPACITY 72-000 <br />gal # OFCOMPARTMENTS 2 <br />ii- <br />GREASE TRAP TYPEIMFG 1 CAPACITY <br />gal # OF COMPARTMENTS <br />❑ PKG TX PLANT DISTANCE To NEAREST: WELL eft' "FOUNDATION <br />It PROPERTY LINE fl <br />❑ LIFT STATION SIZE 1 . TYPE OF PUMP t ❑ SAND <br />q <br />OIL SEPARATOR (ENCLOSED SYSTEM) <br />IX LEACH LINES X LEACHING C # OF LINES LFivGTH OF LINES ` ' f <br />{HAMBERS <br />DISTANCE TO NEAREST WELL .. ft FOUNDATION <br />R PROPERTY LINE f <br />❑ FILTER BED WIDTH ft LENGTH ft <br />DEPTH f <br />DISTANCE TO NEAREST WELL 'ft FOUNDATION/ <br />ft PROPERTY LINE f <br />LI MOUNDED - WIDTH ft LENGTH ft <br />DEPTH f <br />DISTANCE TO NEARtEST WELL ft FOUNDATION <br />R PROPERTY LINE .. f <br />C3 sumps WIDTH ,f — ft LENGTH ft <br />DEPTH f <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE f <br />❑ DISPOSAL PONDS WIDTH�g LENGTH ft <br />DEPTH f <br />_ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION I <br />ft - PROPERTY LINE f <br />❑ SEEPAGE PITS NUMBER IwIDTx ft <br />DEPTH f <br />DISTANCE TO NEARIEST WELL R. FOUNDATION <br />ft PROPERTY LINE f <br />I HEREBY <br />CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE,WITH SAN JOAQUIN COUNTY <br />.�,� y���� , :??=^• •^'R� x: _•_a;..+*ic n�a s—eN .IOA�_IIIN C.OUNTY...: <br />l�NM3A! <br />SIGNED <br />/ -- PIP <br />ExriTwG PJ <br />4400 ^ I <br />R C• <br />]� ./WELL �. --.•�,/t I' � �— � <br />� _ _ � <br />s' � �- w.t� <br />•� <br />pr.�.si <br />' I °G+ <br />Y <br />.,RIµE/per' p AICD <br />L I <br />I <br />HINE -DEMd IS to <br />P,gYME j <br />, ' <br />RECEIV i <br />MAY 2 5 20 7 <br />ly 15 I s 1 \ <br />SAN JOAQUIN COU NTY <br />ENVIROOE NMENTq <br />r <br />Applicationlintion Acce ted By I +.�r.4 -:r Date _ Employee- <br />ID# -7V 3-7Fnal Inspection By Date SPECIAL PERMIT Approved by f <br />Character � . <br />of Soil to Depth of 3 Ft: :i it/Sump Soil Character: <br />OL.O.. e-oy` r7 F /vv .. <br />I COMMENTS ,�£ Go ✓� /J <br />cam— <br />I PE SC Received Amount Date Permit/ ` Invoice # Permit ID# <br />I Code INFO By Cash - Remitted Service Request #- <br />42--13 (f t< 50 -1,14-5-0, 1,-0 <br />42-02-001 /litlj$zGifL✓r in / /�! % ✓ '%�l- k w • S- <br />1212212003 <br />k-'�6rl$ITE WASTEWATER PERMIT <br />12rz2rzoos ', y3s�sc��lYYyi� <br />�.5 <br />I <br />ss <br />