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�+ ONSITE WASTEWATER TREATMI SYSTEM PERMIT <br /> SAN JaUmmIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202.(209)4611-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953.7997 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS l CmrmP M <br /> CROSS STREET APN PARCEL SUE <br /> l OWNER NAME PHONE <br /> v OMER ADDRESS CRYISTATEI I <br /> CONTRACTOR PNONE / L <br /> CONTRACTOR ADDRESS C"/STATE" C <br /> LICENSE QC-42 QC-36 OTHER NUMBER EXNUTION DAT! <br /> WATER TABLE DEPIN: ft GEOGRAPHICALINFORMATION: Coordinates % Y <br /> ��q PERCTEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE i INUI ❑ NEW INSTALLATION ❑ Re AWAomxnON ., ENOWEERDERBNEOIALTBILNM <br /> ❑ REPLACEMENT C OUT-OFSERNICE SEPTICSYBTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCWL ❑ OTHER <br /> NUMBER OF LIVWG UNIT: NUMBER OF BEDRODIm: NU ROFEM onn: <br /> ❑ SEPTIC TANK TYI E MFG CAPACm' SBI #of COMPARTMENTS <br /> ❑ GREASETRAP TYPE/MFG CAPACDY SBI #OFCOMPARTMENTS <br /> DISTANCE TO NTUWEST: WELL ft FOUNDATXW It PROPERTY LINE k <br /> ❑ LIFTSTATION SUE TYPE OF PUMP O IRKS TX PLANT Cl SAND t%LSEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #olUMES LENGTHOFLBIES ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAImST WELL ft FOUNDATION ft PROPERTY UNE ft <br /> O SUMPS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCETONEAREST 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 R <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> _ DISTANCE TO NEAREST WELL ft FOUNDATION k 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 ORDMANCES, �- <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAOUM COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7997 <br /> SIGNED TITLE II-I, DATE <br /> f 'IN JN AE Ufi I <br /> J <br /> DEPARTMENTPHSEONIY <br /> AppNhtlon ADoMBG By c.�. ((.,(,�— Dab :T '- !r7 ARB EmP"ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved M <br /> f9Taeet r of SOH Lo Depth of S FE PIVSump Soil Character: <br /> COMMENTS <br /> PE SC Rehired Amount DTA PermM Invoice III Pennt III <br /> 11aY IMro Ceeh RemNlad Service # <br /> 427? Sae t. <br /> 4aOt ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> OfM6e <br />