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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-KEFUNDABLE VERMIT IL;ALL (ZU,4) <br />.90J-t0Vf FUR 1NSPEG71UN5 <br />tXNIKL5 'I Y tAKK I-KUIVII IJAI t I55Ut <br />JOB ADDRESS D , <br />CITY/ZIP lP%��)' <br />1-1�4- <br />LEACH LINES <br />CROSS STREET V 16'4-C"- l� <br />APN A G; 0 <br />PARCEL SIZE <br />'�� / <br />OWNER NAME C ✓ I ZiV l�I L <br />DISTANCE TO NEAREST WELL ft <br />PHONE <br />ft <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />WIDTH ft LENGTH <br />ft DEPTH <br />CONTRACTOR �I /"�l� � <br />PHONE r: <br />�j <br />- 349- �-6)2/ <br />DISTANCE TO NEAREST WELL ft <br />/ <br />CONTRACTOR ADDRESS p 31 � 0 / SGS! FI <br />' CITYISTATE/ZIP <br />�� j r4- <br />a(� <br />G�v <br />❑ <br />LICENSE �C-42 ❑❑C-36 OTHER <br />// <br />NUMBER �$ `%0T'!; EXPIRATION DATE <br />l —16 <br />DISTANCE TO NEAREST WELL ft <br />\ 1 <br />WATER TABLE DEPITH: ft ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: U NEW INSTALLATION X REPAIRIADDITION U ENGINEER DESIGNED /ALTERNATIVE <br />❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: '* RESIDENCE ❑ COMMERCIAL ElOTHER a �` <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: 6-;2 NUMBER OF EMPLOYEESt ,u <br />❑ <br />❑ <br />SEPTIC TANK <br />GREASE TRAP <br />LIFTSTATION <br />TYPE/MFG 4 S % <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL ft <br />SIZE TYPE OF PUMP <br />CAPACITY gal # OF COMPARTMENTS <br />CAPACITY gal # OI�MPARTMENTS <br />J <br />FOUNDATION ft PRgPcA��K� U��Wll' <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATf3�(E TEM)MFNT <br />ft❑ <br />❑ <br />LEACH LINES <br />)D' <br />�y LEACHING CHAMBERS f 0 C 61411 �q <br /># OF LINES � LENGTH OF LINES � <br />ft <br />DISTANCE TO NEAREST WELL ft <br />I � <br />FOUNDATION �� ft PROPERTY LINE C[� <br />ft <br />❑ <br />FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ <br />SUMPS <br />WIDTH fl LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft -- PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />SEEPAGE PITS <br />> <br />NUMBER WIDTH 3 <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL %,PO ft <br />FOUNDATION 00 J ft PROPERTY LINE <br />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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED_ �_� �L_— TITLE C�1T/yti 14"- DATE <br />PE SC Received heck Amount Date Permit/ <br />Code INFO By, ash Remitted Service Request # <br />Invoice # <br />Permit ID# <br />Z 1� <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4124/12 <br />