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"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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 3 �G �`( �(��I Aj! -e� �J�J 'CIATY/ZIP FCench. ce-k- C- Z <br /> CROSS STREET //XPN � �^/)� ! PARCEL SIZE . W C <br /> OWNER NAM I��•I/ PHONE v; <br /> OWNER ADDRESS CITYISTATE/ZIP <br /> CONTRACTOR 144, 1 �S yc;tCf,�, _ ~ Lf D�S <br /> �� t/:r! PHONE 6 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP kfl"V�.4�L/4 g5:1? ? L.+ <br /> ��,,// o <br /> LICENSE 1:11-IC-42 h_ C-36 OTHER NUMBERCO0<S �f EXPIRATIONDATE <br /> WATER TABLE DEPTH:,,�-v�- it GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: LI NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESI NED/ALTERNATIVE <br /> REPLACEMENT 1-1 OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑. COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> P"o'-SEPTIC TANK TYPE/MFG �� L CAPACITY 16 Wo gal #OF COMPARTMENTS_ <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 PUMR. ❑ PKG TX PLANT 0 SAND OIL SEPARATO NCLOSED SYSTEM) <br /> NLEACH LINES D LEACHING CHAMBERS #of LwEs !i LENGTH OF Lw ft <br /> DISTANCE TO NEAREST WELL r ft FOUNDATION 4-4'h' 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 Zeft DEPTH ft <br /> DISTANCE TO NEAREST WELL �_ <br /> _ ft FOUNDATION - f ft PROPERTY LINE 19 rx ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft 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 /> MINIMUM 48 HOUR44DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7197 <br /> SIGNED TITLEf,-nO tCC TA,r DATE <br /> O <br /> T <br /> ,,D�Date <br /> TMENT U5, E NLY <br /> Application Accepted y ` _ Area Employee ID#�/ � <br /> Final Inspection By Date-�-Q ❑ SP CIAL PERMIT-Approved by <br /> Character of Soil to pth of 3 t: Pit/Sump Soil Character: <br /> COMMENTS <br /> k5AACIL 67r <br /> f <br /> Ise od -- <br /> PE SC Received he Amount Date Per Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/1 B <br />