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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3`°FL-STOCKTON CA 95202-(209)468-3428 <br /> NON-REFUNDABLE PERMIT CA LL,(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS L L C E 4* . CITYIZIP r Q <br /> CROSS STREET t. J , APN t 'a "`7 O'2� PARCEL SIZE <br /> F OWNERNAME !`t'" FR Ic{::r- I,-!t V. f�1-tw PHONE <br /> OWNERADDRESS G "1 �1' `•� .. L. (� l s,.'t t f 1!— .17. CITYJSTATEIZIP �..I A 1�A C'�?�Lf1 <br /> CONTRACTOR ��J PHONE <br /> CONTRACTOR ADDRESS <br /> '-'4:z -T CITYISTATE1ZIP G. ft- rl ti O <br /> LICENSE ❑CA2 ❑C-36 OTHER ' NUMBER Expip-ATIONDATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y., <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# :'A -0-7L(; <br /> j TYPE OF WORK: ❑ NEWINSTALWTION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNEDIALTERNATIVE <br /> s. ❑ REPLACEMENT . ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> 1� NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEJMFG CAPACITY gel #OF COMPARTMENTS <br /> k R ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION R PROPERTY LINE fl <br /> ❑ LIFT STATION- SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> *' ❑ LEACH LINES 0 LEACHING CHAMBERS #OFLINES LENGTH DFLINES R <br /> DISTANCETO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ FILTER BED WIDTx ft LENGTH ft DEPTH R <br /> J - DISTANCETONEAREST WELL R FOUNDATION R PROPERTYLINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH R DEPrH ft <br /> DISTANCETONEARESr WELL R FOUNDATION fl PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH R DEPTH R <br /> DISTANCETONEAREST WELL R FOUNDATION fl PROPERTY LINE ft <br /> s ❑ DISPOSAL PONDS WIDTH 'ft LENOTH R DEPTH R 1 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> ❑ SEEPAGE PITS NUMBER WIDTH it DEPTH R <br /> S DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> IIIw MINIM UNI 24 HOUR ADVANCE NOTICE REQUIRED FOR IN'SPFCTIONS-PLEASE CALL(209)953-7697 f <br /> 4 SIGNED TITLE DATE, <br /> F <br /> - - 1 <br /> S O p 1N qgfry <br /> E VI O M NT <br /> ( . <br /> u` <br /> 1' <br /> t FIT- <br /> DEPARTMENT US yON Y L4 _j <br /> Application Accepted By .L-� — "t--"--��- Dale f_l� O7 Area Employee IDN <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 FC Pit/Sump Sall Character: <br /> COMMENTS <br /> PE SC Received Cheec Amount PermiU <br /> Date Invoice# Permit IDN <br /> Code INFO BY. Cesh Remll[ed Service Request# <br /> w2Z2 X21 t� �r� ] ?F ry {1�`lfc-) Zj `l <br /> Y ' <br /> 42-02-061 ONSITE WASTEWATER PERMIT <br />}' 12R212a61 <br />