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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 EWEBER AVE -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Q A/' CITY/ZIP 4 <br /> to <br /> � APN PARCEL SIZE <br /> CROSS STREET �� & aC <br /> OWNER NAME C .M - t - PHONE <br /> OWN£RADDRESS CITYISTATEIZIP <br /> CONTRACTOR / (J f �/[/t�l"ri7/� \G _, PHONE <br /> CONTRACTOR ADDRESS ,�/!!/C/ i.:iJ �i[i �ii+'vc� __ CITY/STATE/ZIP <br />' LICENSE C42 ❑C-36 OTHER NUMBER DY� EXPIRATION DATE •�7 JZ {\ <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X ti, 4 VVV <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: Ll NEW INSTALLATION REPAIRIADDITION :3 ENGINEER DESICNEDIALTERNATIVE / �5 <br /> REPLACEMENT ❑ DESTRUCTION V <br />{ INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL El OTHER <br /> NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: 952 NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG �'YJSfix cp CAPACITY ICZ* gal #OF COMPARTMENTS Z <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION tt PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE • TYPE OF PUMP LlSAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINESLEACHING CHAMBERS OF LINES _ LENGTH OF LINES loo ft <br /> ` r A <br /> DISTANCE TO NEAREST WELL 5V-�O_ ft FOUNDATION : Fd ft PROPERTY LINE ,S ft <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE tt <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft. <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE tt <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION tt PROPERTY LINE fl <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft <br /> i DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT 1 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 /> I � <br /> SIGNED TITLE ', aVj" DATE��J <br /> r <br /> r` <br /> -3 <br /> ) <br /> I /40'4 <br /> ,- <br /> I <br /> h'c <br /> I <br /> ' CL <br /> G <br /> srION <br /> t <br /> lo <br /> k <br /> M <br /> DEPARTME T U5 �ONLY <br /> Application Accepte Date a{ �" r Area �1 Ere[D# <br /> Final Inspection By Date Z ElSPECIAL PERMIT-Approved by <br /> SAN JOAQUIN COUNTY <br /> Character of Soil to pth of 3 Ft: Pit/Sump Soil Character: 7NVFZQNMFNTA <br /> COMMENTS ' /f - wear o ART EN� <br /> PE SC Recei ed Amount Date Permit/ Invoice# PermitlD# <br /> Code INFO Ca Remitted Service Request# <br /> z. <br /> 42-0`-ao�� <br /> ONSITE WASTEWATER PERMIT <br /> 12/2102 <br /> k _ - <br />