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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET -STOCKTON CA 95202 -(209)468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE I SUED <br />JOB ADDRESS__1,-,7~;;J.:..S",-!..(-,.--,S",--,.--,I-'.<'"..:"'-':.:'f7-_0!.L.!J..:v,-,d,,-,-.CITYIZIP ~dD'••'0,c C e,•:/~__/J.# <br />CROSSSTREET__.,--...:h~:%<:':CY;:::.L...~"'_~&"",~I<£...APN ....L./,-';;;L..L."9:........!O~b}'-'O""--...:...-::-'O?::L.__PARCELSIZE --"~Y0'~7~~ <br />OWNERNAME __--"('_O=.__""q_-f-'-_-=~'--"<'"'•.•.."'--_'=t=""...:'l>49-'y"'-".W·"'-"'"-PHONE ;Z Q,-<f?8 -.3 q 12 <br />OWNERADDRESS_.J(~«,",QL..l..D,--_,E=...--,r,,-,.••c"';;:'::-"---"{L.:!-f,-,-CITY/STATEIZIP ..:::?t%5'dn ('1"/ <br />CONTRACTOR__"'9'-"'.-<..J1'-+,...,<..'"-.......:C>:::....::..J-9'-'''''''·'''e..:!./."d.''--PHONE ;:,-)\)-,G;;J ";?81(/ <br />CONTRACTORADDRESS _Le~._C!:::...·'-"a:"'o"-">r_-'I'-'G."-'Z'-",[CITY/STATEIZIP 'YnO cI /.....4 C".'i S7 7 C <br />LICENSE QC-42 QC-36 OTHER....:..I).L"_C.::..:":z.='-t-,....:..1-1"'.:.:-e,=NUMBER 3.22")'i 1 <br />WATERTABLE DEPTH:It GEOGRAPHICALINFORMATION:Coordinates :![7f?OY':Y/3/Xf"Y -/q>/.Y,20.3~Y~ <br />LI~D~~PE~R;C;T~E~S~T~#~;===~~~~I I;B~UI~L~D:IN~G~P~E~R~M:I~T~#~~~~~~==~L~AN~D~U~S~E~AP::PL~I;C;AT~I~O~N~#~~~~~~~,-I <br />TYPE OF WORK:r-New INSTAlLATION REPAIR/ADDITION «:»:ENGINEER DESIG~JAi.TERNATIVE \_D <br />..--REPLACEMENT OUT~F-SERVICE SEPTIC SYSTEM ..A.DESTRUCTION ./A""'"~ <br />o COMMERCIAL 0 OTHER _ <br />EXPIRATION DATE _ <br />o RESIDENCEINSTALLATIONWILLSERVE: <br />NUMBER OF LMNG UNITS:NUMBER OF BEDROOMS:NUMBER OF EMPLOYEES: <br />[]SEPTIC TANK <br />[]GREASE TRAP <br />[]LIFT STATION <br />TvpE/MFG CAPACITY gal #OFCOMPARTMENTS _ <br />TypE/MFG CAPACITY gal #OF COMPARTMENTS _ <br />DISTANCE TO NEAREST:WELL ft FOUNDATION ft PROPERTY LINE ft <br />SIZE TYPE OF PUMP 0 PKG TX PLANT 0 SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LENGTH OF lINES ft " <br />ft PROPERTY LINE ft ~ <br />DEPTH ft R3 <br />ft PROPERTY LINE ft (~ <br />DEPTH ft \;. <br />ft PROPERTY LINE fl <br />DEPTH ft \\ <br />ft PROPERTY LINE fl <br />DEPTH fl \.1 <br />ft PROPERTY LINE ft ~~ <br />DEPTH ft \\ <br />ft PROPERTYLINE ft \~ <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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209)953·7697 <br />~ <br />DISTANCE TO NEAREST WEll _ <br />WIDTH ft LENGTH _ <br />DISTANCE TO NEAREST WELL _ <br />WIDTH ft LENGTH _ <br />DISTANCE TO NEAREST WEll _ <br />WIDTH fl LENGTH _ <br />DISTANCE TO NEAREST WEll _ <br />[]DISPOSAL PONDS WIDTH ft LENGTH _ <br />DISTANCE TO NEAREST WELL _ <br />[]LEACH LINES <br />[]FILTER BED <br />[]MOUNDED <br />[]SUMPS <br />[]SEEPAGE PITS <br />o LEACHING CHAMBERS _ <br />NUMBER _ <br />DISTANCE TO NEAREST <br />#OF liNES <br />ft FOUNDATION <br />ft <br />ft FOUNDATION <br />It <br />ft FOUNDATION <br />It <br />ft FOUNDATION <br />It <br />ft FOUNDATION <br />It <br />ft FOUNDATION <br />WIDTH _ <br />WEll <br />-~~----~-=~~~--~~~~LJ....J_L.L-:;;"...."'E=~'<"./50~"'"T>-o",BlVd <br />.DEPARTME~USE ONLY <br />Application ce By 7 "'<'<~~!/Date Wc?O Area,"i6?9-~"'~Final Inspection By Date 0 SPECIAL PERMIT -Approved by _ <br />Character of Soil to Depth of 3 Ft:PitlSu p Soil Character:. <br />COMMENTS oL h <br />SIGNED _"TITLE <br />/~ <br />'r\------\-:-..•\r, <br />\ <br />~z Ji~i•!I J.s lr-..i•~i! <br />ft <br />DATE _ <br />pfJi. <br />RE~ <br />I,-rEO <br />.A <br />~II'I"UI,....:0 <br />Employee 10# <br />1:1 <br />PE SC Received Check#lffi ~Amount Date Permitl Invoice #Permit 10#Code INFO By Cash Remitted Service Reauest # <br />..>;;?';;?./0/0.:;?I'""'-'2»/c6a::./0::7.CJ:.:)V.£~~O/-5, <br />42-01 <br />6126109 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT