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4 <br /> 4 • <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 PERMIT CALL/2y09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISS <br /> UED <br /> JOB ADDRESS ['�C-0:CL l�i S CITY/ZIP e Lyle'!" �?L / v <br /> H <br /> CROSS STREET ��yO APN 0 ��-�D L PARCEL SIZE 22, <br /> OWNER NAME /f.L DL./! Lf C'GC`G1 U PHONE D / / .2& <br /> OWNER ADDRESS '�- �+ a O o : ��<<�'f�' ✓'�/�' /\ CITY/STATE/ZIP s; <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑❑C-42 ❑11C-36 OTHER NUMBER EXPIRATION DATE <br /> !V <br /> WATER TABLE DEPTH: OV ft GEOGRAPHICAL INFORMATION: COordin tes X Y <br /> n:• <br /> ❑ PERC TEST # BUILDING PERMIT# Z LAND USE APPLICATION# <br /> TYPE OF WORK: X NEW INSTALLATION LI REPAIR/ADDITION L ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ESIDENCE n a�di wt�, III COMMERCIAL El OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 2 NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG L , CAPACITY / - gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> v1 LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES -� ft <br /> DISTANCE TO NEAREST WELLA-1 ft FOUNDATION �D 1 ft PROPERTY LINE ft <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 /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEA ST WELL ft FOUNDATIONft PROPERTY LINE ft <br /> )4/SSEEPAGE PITS NUMBER WIDTH 1 fl DEPTH G - - ft <br /> DISTANCE TO NEAREST WELL Qft FOUNDATIONft PROPERTY LINE Z, t 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 q HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697) <br /> SIGNED �IZLGGJ TITLE 0( )QP,,1 DATE 5 -27- .20I <br /> A U <br /> N E T <br /> M <br /> DEPARTMENT SE ONLY <br /> Application Accept4Dth <br /> / �L Date , Area 1� Employee ID# w <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil tof 3 Ft: Pi Imp Soil Character: <br /> COMMENTS ��,�(� ( ' I r '� r-cy- uo2'4cd/ ni' Ip Q6- ' !c S t <br /> sY� M�r." it I' S . V(�Y( OY1 OY1Z C 'f 1� Stet m <br /> PE SC Received Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Re uest# <br /> b/, I I�Q <br /> V F�J <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />