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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3- FL- STOCKTON CA 95262 - {2091468-3420 <br />n v14-ttEI1UNDABLE PERMIT <br />CALL 4209) 953-7697 FOR INSPECTIONS <br />EXPIRES l/� YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />7- D5- <br />raL•✓1d �- <br />CITYIYJP L2L��yq <br />WIDTH A LENGTH <br />95Z3+ <br />CROSS STREET <br />61i 12.A <br />rAI j <br />APN 05-1- '3'�(� -• 6(g <br />WIDTH R LENGTH <br />PARCEL SIZE <br />OWNERNAME <br />`� <br />jTt,OS6- N <br />:1 <br />❑ SUMPS <br />PlIONE <br />ft DEPTH III <br />OWNERADDRESS <br />1F� Fey <br />5:(g 5-e)49 <br />CITY/STATE/ZIP <br />DOUlC1/h <br />T/ /�1 <br />CONTRACTOR <br />fV.Q.A � 0 • I"t'VILLJX�'Sll�h <br />/� /� <br />Pruac • <br />T <br />ft DEPTH ft <br />1 <br />� (P'T �-O <br />CONTRACTOR ADDRESS ={0z- <br />t4�- <br />�VI(All,/S'jYIOLy —j ww <br />CITYISTATE/ZIP <br />1PHONEI <br />V"9tyL.l <br />� qs-Loo <br />LICENSE ❑ C42 <br />❑ C-36 <br />OTHER <br />NUMBER <br />EXPIRATION DATE <br />• --- • 1L laCV1iKA YH1L'AL INFORMATION: Coordinates Y j' <br />PERC TEST (S) NUMBER LAND USE APPLICATION # FA <br />TYPE OF WORK: LJ NEW INYIALLATION ❑ REPAWADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br />❑ REPLACEMENT ❑ DESTRUCTION _ <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUh1BER OF BEDROOMS: NUMBEROFEMPI.ovrrs_ <br />❑ SEPTICTANK <br />❑ GREASE TRAP <br />❑ PKG TX PLANT <br />❑ LIFT STATION <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCETONEARTST: \VEIL. <br />SIZE TYPE OF PUMP <br />MI. <br />CAPACITY gal # OF COMPARTMENTS <br />CAPACI I Y gal # OF COf11PARTMENTS <br />FOUNUNLION ft PROPERTY LINE ft <br />D SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />❑ LEACHING CHAMBERS # OF LINES <br />LENGTH OP LINES fl <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />R PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH A LENGTH <br />R DEPTH t3 <br />DIS-IANCE TO NEAREST WELL ft FOUNDATION <br />_ft PROPERTY LINE_ IL <br />❑ MOUNDED <br />WIDTH R LENGTH <br />ft DEPTH fl <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />11 PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH 6 LENGTH <br />ft DEPTH III <br />DISTANCETONEAREST WELL R FOUNDATION <br />ft PROPERTY LINE fl <br />❑ DISPOSAL PONDS W1DTB 11 LENGTH <br />ft DEPTH ft <br />DISTANCETO NEAREST WELL _ __ ft FOUNDATION <br />ft PROPERTY LINE it <br />❑ SEEPAGE PITS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCETONEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <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 LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN <br />COUNTY, <br />HO/UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- <br />PLEASE CALL (2091953-7697 <br />,MININIUM <br />SIGNED—SIC-•y1i'+.-�.s <br />�24I <br />/U.(JI �- Aadj ,n -TITLE �t'11/I t6Y1D1�SPdtTat�{ <br />N.f��DATE ��lJf <br />A <br />O <br />T <br />ApplicationAcce to y Z�Date ' <br />Final Inspecil Date <br />Character of Soil to pth of Ft: <br />COMMENTS r2i21 c <br />PE SC Received .het Amount Date <br />Code INP. Rv Cash Remitted <br />al Lw1BL_19�� 9� �y1 <br />SF.O .V <br />If <br />Area Emplopen[D#_�—lF/�� <br />?-D ❑ SPECIAL PERMIT - Approved by <br />it/Sump Sol] Character: <br />Sen'ice •Realwst# I "'olce# I PermlllDN <br />42-01-001 <br />1 LIM2 ONSITE WASTEWATER PERMIT <br />