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F <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 209 953--7697 FOR INSPECTIONS+ EXPIRES f1'YEAR FROM DATE ISSUED <br /> JOB ADDRESS I ` I ` G C Dd U1 CITYIZIP L C/� '3 )—��1/] y <br /> �I � to <br /> CROSS STREET APN // '7�/ 0 l PARCEL SIZE C C <br /> OWNER NAME �Z PHONE <br /> 2m <br /> OWNER ADDRESS / 7 G� CITY/STATE/ZIP C,�p e1/ C� -2cl 7 <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE ❑❑C-42 110C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ' r ft GEOGRAPHICAL INFORMATION: COOrdites X Y <br /> ❑ PERC TEST # BUILDING PERMIT SAND USE APPLICATION# <br /> TYPE OF WORK: P., NEW INSTALLATION ❑ PAIR/ADDITION u ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL 1�7 ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG u CAPACITY i0 l5 gal #OF COMPARTMENTS 4 <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 /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES l LENGTH OF LINES C5;� ft <br /> DISTANCE TO NEAREST WELL J 2-0'+ ft FOUNDAT10N� 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 NEARS T WELL ft FF(O,U,N,DAT10N ft PROPERTY LINE ft <br /> q� SEEPAGE PITS NUMBER WIDTH l7G,r ft DEPTH ? t ft <br /> /\ DISTANCE TO NEAREST WELL L�jft FOUNDATION I l7 ' ft PROPERTY LINE 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 /> MINIMUJW `}BHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 <br /> SIGNED L�� TITLE LL `y DATE I I t <br /> IVT <br /> I/ 8 <br /> y C <br /> T <br /> QE ARTMENT SE N Y <br /> Application Accepted By Date 1 Area Employ91D# 5Vt7 <br /> Final Inspection By Date wry 77 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS 11 1'1 ": .Lmt ec�-_d inytk cwd lecAck knee SamIV!244e.c ue-t fD be (+I1.Shlleck anus. <br /> W,)_ 5Sc a c L —Suk1\,rej. <br /> PE Sc Received ChecI41 Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Ely as emi ed Service Request# <br /> + II 13 I 5 <br /> 42-01 1 7 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 37 ZI <br />