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' ONS['1'E `VAST1,.WATER TREATNIENI' SYSTEM PERMIT <br />SAN JOAQUIN COLNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEDER AVE -3'" FL- STOCKTON CA 95202 - (209) 468-3420 <br />INVIN-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES ( YEAR FROM DATE ISSUED <br />JOB ADDRESS /] CITY/ZIP <br />CROSS STREET APN,�=7' O — (I PARCEL SIZE XnAl gGlt, <br />OWNERNAVTE Yom. rbn Lit'fy/G�fl PHONE SY� <br />OWNERADDRESi �.t\t--CTIY/SFA7VZIP I- ' , CA <br />CONTR\CFOR n, p 1��� C „may, n� 2m �— PHONE 2-0 Ct —�' I �_ <br />CONTR\CTOR ADDRE.iS -G OJ,,,,.J 7�. IVl ljj"`"' [ 1(�� CITYISTAT[IZIP- .�_CA <br />LICENSE ❑ C-42 ❑ C-36 OTIIER NUMBER EXPIRATION DATE <br />•IAILH IAULL uLPI"Nl <br />It GEOGRAPHICALINPORMATION: Coordinates X <br />y <br />FERC TEST (S) <br />NUMBER <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />❑ NEW INSTALLATION <br />❑ REPAIRIADDITION <br />❑ ENGINEER DESIGNED/ALTERNATIVE <br />❑ REPLACEMENT <br />❑ DESTRUCTION <br />FI INSTALLATION WILL SERVE: ❑ RESIDENCE <br />L3 COMMERCIAL <br />❑ OTHER_ <br />N UMBER OF LIVING UNITS: <br />NUMBER OF BEDROOMS: <br />NUMBER OPEMPLOYEES: <br />❑ SEPTICTANK <br />TYPF/MFG_ <br />CAPACITY <br />go] 40FCOMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACrIY <br />gal # OF COMPARTMENTS <br />❑ PICC TX PLANT <br />DISTANcETONEnRF-w: WELL <br />R FOUNDATION <br />R PROPERTY LINE R <br />D L11T STATION <br />SIZE TYPE OF PUMP 0 SAND OIL SEPARATOR (ENiCLOSI D SYSTEM) <br />❑ LEACH LINES ❑ LEACHING CHAMBERS # OF LINES _ LENGTH OF LINES ft <br />DISTANCE TO NEAREST WE+.L ft FOUNDATION R PROPERTY LINE R <br />❑ FILTERBED WIDTN R LENGTH R DEPTH ft <br />DISTANCETONEARIST WELL _ fl FOUNDATION ft PROPERTY LINE fl <br />❑ MOUNDED WIDTH fl UNOTH _ R DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION_ ft PROPERTY LINE R <br />❑ SUMPS WIDTH E fl LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL _ft FOUNDATION- ft PROPERTY LrNE fl <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH R <br />DISTANCE TO NEAREST WELL _.ft FOUNDATION R PROPERTY LME R <br />❑ SECPAGE PITS WIDTH ft LENGTH R DEPTH fl <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE. R <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAW'S AND RULES AND REGULATfONS OP SAN JOAQUIN COUNTY. <br />I I fU.M 24 HOUR ADVANCE NOTICE REQU IP.ED FOR MSPECI IONS- PLEASE CALL (209) 993-7697 <br />D,ATF: <br />Apptk�tlon Accepted By <br />Find Inspection By__` <br />Character of Soll to Dept <br />COMMENTS"��I <br />Employee IDA 13444-411 f <br />-3---11SPECIAL PERMIT -Approved by <br />Soil Ch2recter: <br />