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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> Joe ADDRESS 0 �i• PkDA F- CITY/ZIP �� T(t-N�l .:' /�r <br /> CRO55 STREET 1 o-ue +'t _ APN l O-A— l S Q `� r✓ PARCEL SIZE o <br /> loo:3 <br /> OWNER NAME I -,.�"-vQN i 0 :.7Q[_`&f—A, PHONE <br /> - <br /> OWNER ADDRESSy��P� / 1��yW/ � •�� CITYISTATEIZIP S <br /> C- L �y <br /> CONTRACTORS"O T'i L ' D "'' � �� C— PHONE <br /> CONTRACTOR ADDRESS !r*'^ �` a.LtA..t`S 1kJE; CITY/STATEIZIP <br /> LICENSE *42 LSC-36 OTHER NUMBERS `C/ EXPIRATIONDATE <br /> WATER TABLE DEPTH: _ ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> RERC TEST # BUILDING PERMIT#! LAND USE APPLICATION# <br /> TYPE OF WORK: C- NEW INSTALLATION C RFPAIRIADDITIO 4 IIS ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT 7 DESTRUCTION <br /> iINSTALLATION WILL SERVE: V RESIDENCE COMMERCIAL ❑ OTHER <br /> r NUMBER OF LIVING UNITS: L NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG -Pu1 L CAPACITY!past? gal #OF COMPARTMENTS Z <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> � L ! <br /> DISTANCE TO NEAREST: WELL t VC ft FOUNDATkON �ia f# PROPERTY LINE LQ ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LLEACH LINES W LEACHING CHAMBERS -�#OF LINES LENGTH OF LINES t tt <br /> DISTANCE TO NEAREST WELL IC)0, ft FOUNDATION L4 d I �' ft PROPERTY LINE s'.+- It <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <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 ft <br /> LJ DI SPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft yj�V <br /> FOUNDLI <br /> FOUNDATION ft PROPERTY NE ft <br /> SEEPAGE PITS NUMBER^ I0 WIDTH r� ` t * DEPTH 2-� � ft <br /> DISTANCE To NEAREST WELL V .. b t ft FOUNDATION �©�� ft PROPERTY LINE � � ft <br /> 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 /> MINIMSWM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED • TITLE DATE O3 f Z l !l 3 <br /> NT{A <br /> D �1!EQ <br /> a o 2 2013 <br /> Z-' <br /> A ll N COUNTY <br /> - N I ENTAL <br /> Mr-FlAFITMENT <br /> r <br /> L <br /> I \/ <br /> DEPARTME T US ONLY <br /> Application Accept Date; T L� Area 1 L Employee I✓a# 1'17 L <br /> Final Inspection <br /> Date c ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to D th of 3 Ft: Pit!-ump Soil Character: <br /> COMMENTS = �1>`xt4ok _•L, Aw s"tL JDg iLw5 LIti S. Lvw Co_ <br /> PE Sc Received Check#/_ Amount pate Permit! <br /> Invoice It Permit ID# <br /> Code INFO B --CasFi Remitted Service Request# <br /> ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 42-01 <br /> 1014107 <br />