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a <br /> ONSITE WASTEWATF REATMENT SYSTEM SERI* /� y <br /> ��SAN 30AQUIN COUNTY ENV!RO � <br /> NMENTALHEALTHDEPARTMENT �= 304E WEBER AVE-3-FL-STOCKTON CA 952209)468-3420 <br /> � <br /> NON-REFUNDABLE rERMIT CALL(209)953--7697 FOR INSPECTIONS EXPIRES II YEAR FROM DATE ISSUED r <br /> CITYIZIP "`" n <br /> ,JOB ADDRESS D <br /> APN <br /> fCROSSSTREE7 �CPARCEL SIZE <br /> �-a��{�� - <br /> Z5' d <br /> PHONE <br /> OWNER NAME C� �-y <br /> CITYISTATFJZIP <br /> �OWNERADDRESS «..J/ ) r <br /> I / 0M�� PHONE <br /> j`i CONTRACTOR �V <br /> CITS'lSTATEIZIP <br /> CONTRACTOR ADDRESS -- <br /> LICENSE -42 ❑C-36 OTHER p+� ` <br /> NUMBER Lp('* 7-Z— J ExrtRATION DATE !Q a <br /> : <br /> WATER - <br /> ft GEOGRAPHICAL INFORMATION: Coordinates <br /> TABLE DEPTH: LAND <br /> Y V� <br /> I LAND US£APPLICATION# <br /> L3 PERC TEST(S) NUMBER <br /> TYPE OF WORK: <br /> NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENClNEER DESIGNED IALTERNA'tiVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> OTHER <br /> �1NSTALLATIONWILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ <br /> Nu OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> NUMBER OF LIVING UNITS: <br /> FSEPTIC TANK TYPE MFG �P✓CT�u �� CAPACITY sal #OF COMPARTMENTS,__�� 1 <br /> CAPACITY gal #OF COMPARTMENTS <br /> ❑ CREASE TRAP TYPFJMFG pppp��II �!� ft <br /> t � R FOUNDATION� R PROPERTY LINE <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL <br /> s El LIFT STATION S[zE TYPE OF PUMP ❑ SAN6 OIL SEPARATOR(ENCLOSED SYSTEM) <br /> #or LINES-�_ LENGTH OF LINES / `r ft <br /> -44 LEACH LINES ❑ LEACHING CHAMBERS �j�7 �7 <br /> DISTANCETONEAREST WELL ft FOUNDATION�ft PROPERTY LINE JLW ft <br /> A LENGTH ft DEPTH fl <br /> ❑ FILTER BED WIDTH fl <br /> DISTANCE TO NEAREST WELL. ft FOUNDATION fl PROPERTY LINE <br /> t R <br /> (❑ MOUNDED WIDTH R LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPSwmrH A LENGTH ft DEPTH h <br /> ¢� <br /> R { DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH_ A DEPTH ft <br /> ft LENGTH ft <br /> SEEPAGE PITS WIDTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION- fl PROPERTY LINE <br /> 3ft DEPTH_. r j� ft! <br /> DISTANCETO NEAREST WELL ft FOUNDATION - ft PROPERTY LINE —4h-a—ft <br /> !HERESY CERTIFY THAT I HAVE PREPARED <br /> LAWSCATION AND THE WORK WILL BE DONE IN ACCORDANCE <br /> TAND REGULATIONSOF SAN JOAQ IN COUN YWITH SAN JOAQUIN COUNTY. <br /> --ORDINANCES, <br /> { MINIMUM 24 HOURR ADVANCE NOTICE REQUIRED FOR INSPECT NS-PLEASE CALL(209)953-7697 O <br /> 1 SIGNED r OAJT-J �2—da- +1ITLF DATE <br /> x <br /> Atj;,;_ � <br /> I <br /> Y ` <br /> I <br /> F <br /> }IS L <br /> DEPARTMENT SE ONLY Q� <br /> Application Accepted Date 3 23 �r Area Employee ID# <br /> �+ Final Inspection B Date ✓�-Z ❑ SPECIAL PERMIT-Approved by' <br /> k _y Character of Soil to De th of 3 Ft: PitfSamp Soil Character: <br /> @� COMMENTS <br /> C 7 <br /> r <br /> �� � •,�j/ � lC�'/9 x�i�Z�.S.i ct� 7 4Y` it/ayf <br /> I� PE SC Received hec Amount Date PermiU Invoice# Permit ID# <br /> Service Re uest# <br /> Code <br /> INFO B ash Remitted <br /> �f-2--II If�7 � �2cc� CSD <br /> r <br /> 42-0I-001 ONSITE WASTEWATER PERMIT <br /> 121V02 'c--ws <br />