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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NCI CALL 209 953-7697 FOR INSPECTIONS 1EXPAM I YEAR FROM DATE ISSUED <br /> Joe ADDRm 'it a /U, 6 *Cm/zv L. e6. &A <br /> CROSS STREET r hG O aCd - y�,�0- bb "r APN�., PARCEL SIZE .� GAY <br /> OWNER NAME .r aL1 ws v—a t/ . PHONE ZUg-Yrl —4 7 7 / <br /> OWNER ADDRESS Y Z!/ „(J. 1�e La <br /> _ CrrYlsTATElZIP S�Dc C..I�+�. 4f� �q ss <br /> CONTRACTOR ,rV/.if <br /> -- f PHONE <br /> CONTRACTOR ADDRESS A/r,I CITY/STA'I'FJT,IP <br /> LICENSE ❑ C 42 ❑ C-36 OTHER NUMBER • EXPtRA f10N DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X <br /> ❑ PERC TEST k BUILDING PERMIT tf LAND USE APPLLCATiO V# —� <br /> TYPE OF WORK: NEW INSTALLATION 13 REPAIR/ADDmoN ENGINEER DESI D! TERNATIY'E <br /> O REPLACEMENT DI5STRLCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER_ <br /> NUMBER OF LIVING UMTS: NUMBER OF BEDROOMS: _ NUMBER OF EMPLOYEES: _ <br /> ❑ SEPTIC TANK TYPFJMFG __ CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFci CAPACITY gal k OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION _ ft PROPEitrY L.r%E <br /> D LIFT STATION SIZE TYPE OF PUMP D PB.G TX PLANT D SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> O LEACH LINES D LEACHING CHAMBERS N OF LINES LENGTH OF LINES ft <br /> DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft N <br /> DISTANCE TO NEAREST WELL ft FOUNDATION _Il PROPERTY LINE <br /> ❑ MOUNDED WwTH fl LENGTH ft DEPTH 1t ? ! <br /> DISTANCE To NEAREST WELL ft FOIINUArION ft TY LINE fl 1. <br /> D sUMPs WIDTH ft LENGTH ft ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION PROPERTY LINE ft <br /> O DISPOSAL PONDS WIDTH ft L.ENGTI I E ft 1 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH_______ _ ___ _ DEPTH L1 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQU IN COUNTY. <br /> Jim 'M 24 LR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)"3-7697 <br /> SIGNED TITLE. OLaJ✓LG✓ DATE <br /> I <br /> I Lad, <br /> i <br /> { a= '- <br /> r , <br /> I I <br /> I N E P <br /> I � <br /> I <br /> PARTMjpY <br /> AppDcatiou Accepted Date Area _ Fmployce IDk _ - <br /> Final Inspection By Date E3 SPECIAL PERMIT-Approved by <br /> Character of Soil W of3 Ft: p Soil Character: <br /> COMMENTS - - u ?!LAsl�is7715� Se�ri� T^(itlG G tS�1s7.�l�n ctx�Z <br /> coon 35 c-M7 _.._ <br /> PE SC Received C Amount Date Permit/ Invoice If Permit IDk � <br /> Code LYPO Ci Servlee k _-- <br /> i <br /> 42-ul ONSrM WASTEWATER PERM r <br />