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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-KEFUNUABLE I LHMIT <br />ft LENGTH <br />L;ALL LUV V03 -/OV/ FOR INSPECTIONS <br />1 YEARDATE ATE ISSUE <br />JOB ADDRESS <br />LA\ty R� <br />R-0 <br />CITY21P rA Aprq=C^ <br />+EXPIRES <br />7 )) <br />L <br />AD <br />CROSS STREET P'—Cy <br />rt 9J0 <br />APN l -U <br />d d 2 <br />ft PROPERTY LINE ft <br />PARCEL SIZE <br />S 'j 61 <br />OWNER NAME ��� ��v�/y\OS <br />jqy <br />DISTANCE TO NEAREST <br />WELL <br />PHONE <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />OWNER ADDRESS�� <br />ft DEPTH ft <br />CITYISTATE/ZIP <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />,/' <br />CONTRACTOR-I,JIL&Lkzk- <br />,/' l e <br />\\Gµ <br />g� <br />PHONE C`���- b-iick <br />' 9 <br />-- ZA& <br />WELL <br />CONTRACTOR ADDRESS \06 <br />//coi''p]I <br />i �]CSS�w\��^ <br />��/ S( A. <br />CITYISTATE/ZIP <br />V V \ <br />Q <br />lk"" <br />LICENSE ❑._I C-42 ❑:1036 <br />OTHER <br />NUMBER11L6 <br />EXPIRATION DATE <br />k- <br />J <br />WATER TABLE DEPTH: 3 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: k NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT -i OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: '�Rt RESIDENCE L COMMERCIAL ] OTHER <br />NUMBER OF LIVING UNITS: l NUMBER OF BEDROOMS: L NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG tg% L- Gt. ,fXj�' ,d F=IZ- CAPACITY ,1.00 gal # OF COMPARTMENTS L <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES LEACHING CHAMBERS # OF LINES L LENGTH OF LINES 6 0 ft <br />DISTANCE TO NEAREST WELL -2,0 L ft FOUNDATION t ft PROPERTY LINE G1 ft <br />❑ FILTER BED WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS NUMBER <br />WIDTH <br />ft DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE It <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN OAQUIN COUNTY ORDINANCES, <br />STATE LAWS AND RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY. <br />SIGNED <br />Application Accepted <br />Final Inspection By <br />Character of Soil to 11 <br />COMMENTS yI, <br />TITLE AW IIJ, � ;- DATE I("1 -C-0 <br />DEPARTMENT USE ONLY % <br />Date - J / Area 3 L Employee ID# <br />Date ❑ SPECIAL PERMIT -Approved by <br />3 F : PIV p Soil Character: <br />PE SC Received Check#/ Amount Date Permit/ Invoice # Permit ID# <br />Code INFO B Cash Remitted Seryice Re uest # <br />q;1I)► 7 i Ila <- <br />v <br />42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24112 <br />w <br />