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1 <br />PA.��I1E <br />�\Vi� 1 <br />sP'''�Nv1R <br />N��TN <br />ONSITE WASTEWATER TREATM NT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868E t Hazelton Avenue - STOCKTON CA 95205-6232 .(209)468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 9537 FOQI PECTIONS EXPIRES 1 YEAR FROM DATE ISSUE] <br />JOB ADDRESS <br />!' ; ) 't 1 <br />.1 —/ ' 1 CITYILIP 1 \ —, It Imo, <br />I I '? 111 11 <br />CROSS STREET <br />C <br />1 6 �APN� ._.�O 3 <br />PARCEL SIZE <br />OWNER NAME <br />\\lx,\\ <br />1..�1�t t1 <br />PHONE <br />•I.f CAPACITY ^ gal # OF COMPARTMENTS_ <br />❑ GREASE TRAP <br />OWNER ADDRESSI <br />CAPACITY gal # OF COMPARTMENTS <br />CITYISTATFJZIP <br />0` <br />DISTANCE TO NEAREST: WELL <br />It FOUNDATION ft PROPERTY LINE <br />f <br />J ` <br />V <br />_ �I <br />CONTRACTOR <br />1`i `,• <br />\ \ PHONE O� " <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br />7 •� <br />V <br />` 2 <br />CONTRACTOR ADDRESS <br />CITYISTATEIZIP 1 ' <br />1/ <br />,� I <br />pI FILTERBED <br />11 <br />-711 c, <br />1 LAEXPIRATION <br />It <br />LICENSE C-42 <br />, C•36 OTHER <br />NUMBER DATE <br />ft <br />WATER TABLE DEPTH:((/V "IYIV��N f1 GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # LAND USE APPLICATION 9_ <br />Application Accepted <br />Final Inspection By_, <br />Character of Soil to <br />COMME TS' <br />Code INFO <br />c� �/ <br />Dated r3,z <br />Pit/Sump SI <br />Data <br />42-01 <br />1014!07 <br />Area -fq -( - / Employee 10# <br />SPECIAL PERMIT • Approved by <br />Character: <br />Invoice # I Permit ID# <br />ONSITE WASTEINATER TRTMNT SYSTEM PERMIT <br />J Ap <br />.sJ cNh�l l nn <br />REPLACEMENT <br />DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE <br />COMMERCI L OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG 1 � <br />•I.f CAPACITY ^ gal # OF COMPARTMENTS_ <br />❑ GREASE TRAP <br />TYPEIMFG <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />It FOUNDATION ft PROPERTY LINE <br />ft <br />❑ LIFTSTATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br /># of LINES LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST WELL <br />it Il PROPERTY LINE <br />ft <br />pI FILTERBED <br />WIDTH -00 ft LENGTH <br />?FOUNDATION <br />i 3l ft DEPTH <br />It <br />DISTANCE TO NEAREST WELL <br />�. <br />It FOUNDATION -��') It PROPERTY LINE il-: <br />ft <br />❑ MOUNDED <br />WIDTH f1 LENGTH <br />ft DEPTH <br />it <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION it PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH It LENGTH <br />11 DEPTH <br />Il <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION ft PROPERTY LINE <br />it <br />❑ DISPOSAL PONDS W DTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCETO NEAREST WELL <br />It FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />It DEPTH <br />it <br />DISTANCE TO NEAREST WELL <br />it FOUNDATION rt PROFER-Y LINE <br />It <br />I HLn EBY CERTIFY 'tI1AT I HAVE PREPARED THIS APTLICATION AND THE <br />WORK PILL BE DON`_ IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAW AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />hU <br />NI 24 HQy P� JC N TICE R UIRED <br />FOn PE IONS - PLEASE CALL (209) 953-T6D9A7 <br />SIGNED <br />VA <br />II' �� <br />j <br />LE <br />Application Accepted <br />Final Inspection By_, <br />Character of Soil to <br />COMME TS' <br />Code INFO <br />c� �/ <br />Dated r3,z <br />Pit/Sump SI <br />Data <br />42-01 <br />1014!07 <br />Area -fq -( - / Employee 10# <br />SPECIAL PERMIT • Approved by <br />Character: <br />Invoice # I Permit ID# <br />ONSITE WASTEINATER TRTMNT SYSTEM PERMIT <br />J Ap <br />.sJ cNh�l l nn <br />