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L <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIIT/� CALL 209 953-7697 FOR INSPECTIONS /EXPIIR�ES 1 YEAR F�RO/M�DATE fiSSUED <br /> JOB ADDRESS l Cr' Irj/} P CITY/ZIP GOIdi, ( t— <br /> 'yam �/� l� <br /> CROSS STREET U✓r i,� F-=GAG(�� APNOb l —I`t�V -Q[Iyn PARCEL SIZE <br /> OWNER NAME1JAIKO H c PHONE <br /> OWNER ADDRESS L� CITYISTATE/ZIP ?/� <br /> CONTRACTOR cey)1 q I // � �l�l /� G PHONE �0 1 ^/✓6, <br /> CONTRACTOR ADDRESS �,3/ 6 0/SOI? t),• CITY/STATE/ZIP «/�`/ <br /> LICENSE 0�(42 ❑❑C-36 OTHER NUMBER EXPIRATION DATE <br /> I <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑-P ERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: U NEW INSTALLATION U REPAIRIADDITION U ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: /n /) NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG Ohl/P� //' L CAPACITY ��Nw gal #OF COMPARTMENTS a <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> � <br /> DISTANCE TO NEAREST: WELL AGO ft FOUNDATION � ft PROPERTY LINE <br /> 7/ ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES /3 LENGTH OF LINES /�5 � ft <br /> DISTANCE TO NEAREST WELL �00 ft FOUNDATION &0 / ft PROPERTY LINE 7 G ~ ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ANA. <br /> y.ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ���� <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE [ <br /> SUMPS ��j, WIDTH ft LENGTH L7 Lft DEPTH pZjf <br /> DISTANCE TO NEAREST WELL j Q ft FOUNDATION Q T ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH SAN rn. ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI ENV CO <br /> lorlt EP LrH L)E 7AL ft <br /> DISTANCE TO NEAREST WELL RRgRSpzF `i rft <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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br /> SIGNED �-- TITLE DATE <br /> S <br /> 161 <br /> Lu <br /> O <br /> r <br /> X <br /> I�ei,��ba5 <br /> ai <br /> tyle <br /> � <br /> [i <br /> v <br /> EPARTMENIJUSHOjVLY <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Dep of 3 Ft: U Pit/Sump Soil Character: <br /> COMMENTS -V/A-[- C-0 itSL- VJ4y'44 <br /> ljDt & Patz rcit �, � I &A:�r a-k(Ajh fiG'M h/UAA Il <br /> 0 S2 c.Rr� C <br /> PE SC Received Ch Amount Permitl <br /> Code INFO B Cash mitted Date Service Request# Invoice# Permit ID# <br /> bZD Q 11-� -� S i2 Ott 1°)$ ��/% <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />