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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P , <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT i CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME IMANI"Woj L QCT%�l�✓ M J <br />OWNER ADDRESS <br />CONTRACTOR K 4# 7 ( V4 <br />CONTRACTOR ADDRESS ffjmg <br />LICENSE X-42 - C-36 OTHER <br />076 -/ V PARCEL suE / +� <br />PHONE 3a 7 -asqg <br />PHONE 9P* •14 ( _ Sbil l <br />� <br />'_t Cm/STATErbP f..9M ��jt • �� `� <br />NWreER I ''. "Ts EXPIRATION DATE ( i/g <br />WATER TABLE DEPTH: bo - l v _ft GEOGRAPMCAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # <br />C A • <br />LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION <br />REPAIR/ADDITION <br />ENei EEiDES101ED/ALTERNATIVE <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM DESTRucT N <br />INSTALLATION WILL SERVE: RESIDENCE <br />COMMERCIAL <br />OTHER <br />NUMBER OF LMNG UMTS: I NUMBER OF BEDROOMS: 3 <br />NUMBER OF EMPLOYEES: <br />DISTANCE TO NEAREST <br />WELL <br />❑ SEPTIC TANK TYPE/MFG I MI W 4 <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />I�'� <br />DISTANCE TO NEAREST: WELL 1 / 0 <br />f1 FOUNDATION <br />10 ft PROPERTY LINE a5 s ft <br />O LIFT STATION SIZE _ TYPE OFPIAIP_ <br />❑ PKGTXPLANT <br />O SAND OIL SEPARATOR (MLOSED SYSTEM) <br />IA LEACH LIMES <br />LEACHING CHAMBERS <br />C A • <br />_ _ _ # OF LINES A_ LENGTH OF LINES <br />` <br />DISTANCE TO NEAREST <br />WELL <br />7d <br />ft FO{IIWTION ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />it FOUNDATION ft PROPERTY LINE --ft <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft DEPTH , ( <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE <br />SUMPS <br />I <br />WIDTH if <br />ft <br />LENGTH <br />Iq I ft DEPTH 81 - <br />DISTANCE TONEAREST <br />WELL <br />00 " ft FOUNDATION 86 / ft PROPERTY LINE <br />❑ DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />It DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE It <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAGUIN COUNTY. <br />Z � m�e <br />0 $i, <br />C A • <br />t Z Lo <br />�0 <br />IV <br />5Y �G <br />PE SC Received Check#/ Amount Date PermlV Invoice# Permit ID# <br />Code INFO Bv Cash FjemijjW Service Request # <br />o On s <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14118 <br />