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tl'W ONSITE,WASTE`VATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE -3'" FL- STOCKTON CA 95202 - (209)468-342D <br />NON-REFUNDABLE MPERMIT - CALL (209) 953-7697 FOR INSPECTIONS . EXPIRES I YEAR FROM DATE ISSUED <br />JOB AnnRrSS Z�cj N <br />CROSS STREET ( L S r i APN (:"N, f `,.3'Z C%' 0,49, PARCEL SIZE <br />OWNER NAME 1� f,.1, Uj�C-CPHONE <br />OWNER ADDRESS -702Z2 <br />Q���I U1 :�}CITY[STATE/ZIP 4�kdd <br />CONTRACTOR PHONE <br />���� <br />CONTRACTORADDRESS L -.,v lED.-I CITYISTATEIZIP OJA ( 'Qtr+.ajrS <br />S �f-} • 43V <br />LICENSE LI C42 QC -36 OTHER q NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X y <br />Q FERC TEST (S) NUMBER LAND USE APPLICATION N <br />TYPE OF WORK: ❑ NEW INNTALLAc'ION ❑ REPALRIADDTI"ION ❑ ENGINEER DESIGNED (ALTERNATIVE <br />❑ REPLACEMENT DESTRUCTION S <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OR RFnRrw1mv Nn..e. ..� c...,....,. <br />❑ SEPTICTANK <br />❑ GREASE TRAP <br />❑ PKG TX PLANT <br />❑ LIFTSTATION <br />TYPElMFG <br />TYPFJMFO <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />CAPACITY_ <br />CAPACITY <br />R FOUNDATION <br />gal 1f OFCOMPARTMENTS <br />gal #0FCOMPARTMENTS <br />ft PROPERTY LINE <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />R <br />❑ LEACH LINES <br />❑ LEACHING CHAMBERS <br />/ <br />4 OP LINES <br />LENGTH OF LINES ft <br />DISTANCETO NEAREST <br />WELL <br />ft FOUNDATION <br />P£ Se <br />Code INFO <br />R PROPERTY LINE ft <br />❑ FILTER HED <br />WIDTH <br />ft <br />LENGTH _ <br />S 0 3 z I a <br />_ ft <br />DEPTH A <br />DISTANCETONEARESr <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE_ ft <br />❑ MOUNDED <br />WIDTH <br />R <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE R <br />❑ SUMPS <br />WIDTH <br />ft <br />LENOTH <br />fl <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FDUNDATION <br />R PROPERTY LINE Il <br />❑ DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />R <br />DEPTH f1 <br />DISTANCETO NEAREST <br />WELL <br />R FOUNDATION,_ <br />R PROPERTY LINE R <br />❑ SEEPAGE PITS <br />WIDTH <br />R <br />LENGTH <br />ft <br />DEPTH R <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />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 />Im 1 Ol 4 DV NCE NOTICE REQUIRED FOR INSPE�CTIONS– PL A��SI/E CALL (209) 953.7697 <br />SIGNED Zi TITLE nN14 DATE L <br />M <br />a <br />S <br />rF <br />e6 <br />N <br />(Q(,, <br />"1 <br />0% T% <br />I, <br />f� <br />Application Acceplcd By C4 A �� �� <br />Final Inspection B licL <br />Character of Soil t epth of 3 Ft: <br />COMMENTS /V � ai-� <br />DEPARTMENT USE ONLY <br />Date ( Areo 21 7— Employee IDA <br />_ Date rJ ❑ SPECIAL PERMIT - Approved by <br />PRISump Soil Characfer: <br />�t 1z . 7 7% f <br />/ <br />P£ Se <br />Code INFO <br />Received Checl�{I <br />B <br />Amount Date PermiU Invoice# Permit IDN <br />Remitted Service R ueal H <br />o -7s <br />1 �,e - 1,339 f3 <br />S 0 3 z I a <br />!-01.001 <br />2i02 ONSITE WASTEWATER PERMIT <br />