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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 /> ` <br /> NON-REFUNDABLE PERMIT p CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1YEAR FROM DATE ISSUED <br /> JOB ADDRESS 32L 3 I G • S P1 ES S ��• CITY/ZIP !•{{/1 p(1lwPIC� <br /> 0 -/l-PZy Z' <br /> 4 <br /> ., <br /> CROSS STREET I;r�/vl I ! W T,"�NT�C APN DOS 3�� I PARCEL SIZE �• !Al0-. o <br /> G p 0 <br /> OWNER NAME TO^1 LN PI E 12r s PHONE 1 <br /> OWNER ADDRESS S0%rV%ECITY/STATE/ZIP <br /> CONTRACTOR WYE: Oryy 6J EC)E)"JVI?-Oy`mEA (rpL PHONE 3(1G- V3' <br /> 5 <br /> CONTRACTOR ADDRESS 4o / W• o Y-- <br /> ST- CITY/STATE/ZIP Lol>I CA '15'7-4-0 <br /> LICENSE I'.0-42 I. C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT Il DESTRUCTION <br /> INSTALLATION WILL SERVE: L RESIDENCE COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG 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 /> ❑ LIFTSTATION SIZE TYPE OF PUMP ❑ PKGTXPLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES G LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH It 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 NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION 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 /> INIMUM ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE GO'A,JS U LT fi-A!T DATE IP — 11— 1'7 <br /> �AYMENT <br /> ECEIVED <br /> n N 18 2019 <br /> AQUIN COUNTY <br /> IRONMENTAL <br /> L DEPARTMENT <br /> EPARTMEN US ONLY �y/ /Q <br /> Application Accepted By Date Area --` 1 ` Employee ID# �L <br /> Final Inspection By Date SPECIAL PERMIT-Approved by <br /> Character of Soil to De hof 3 F: Pit/S Imp oil Character: <br /> COMMENTS T 33 ff*n/)n <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By. I Cash Remitted Service Re uest# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />