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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT )0 CP <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697FOR INSPECTIO%S FXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /Z' I\1 "�/f y CITY <br /> '1/ZIP h <br /> 0 <br /> CROSS STREET / AIN -q -O 6 ,�RC.EL SIZE <br /> OWNER NAME I '� PHONE <br /> OWNER ADDRESS /(J L�/ ! _ (3N"Jr YJ�CI CITY/STATE/ZIP 'C 0 <br /> CONTRACTOR �( PHONE <br /> CONTRACTOR ADDRESS CITY/STAT'F/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE.DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) NLIM13ER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ —ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT DESTRUCTION C <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER r� <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: 1\\� <br /> ..1� <br /> ❑ SEPTIC TANK TYPFIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPFIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION1]OAPFPa,PERTY LINF, <br /> LI LIFT STATION SIZE TYPE OF PUMP (, '� ESI <br /> NIIT- <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF L -S LEND rH Or LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUND N ft P tt'a, <br /> ❑ FILTER BED WIDTH ft LENGTH /DTH <br /> bMOW 1111 Qrade_ AA_rfMl n',...gr�l <br /> DISTANCE TO NEAREST WELL ft FOUNDATIO ftPWI�IwWrequireanawro1Md ft <br /> lift H11fbrl. Mimmum <br /> ❑ MOUNDED WIDTH ft LENGTH ft �P�Of IydtiDISTANCE TO NEAREST WELL ft FOUNDATI ftP PRp_ER I Um so'Cpl,e(ow <br /> ❑ SUMPS WIDTH ft LENGTH C1�IIOM <br /> DLSTANCE TO NEAREST WELL R FOUNDATIS XI " t PROPERTY LINE tt <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH tt <br /> DISTANCE TO NEAREST WELL A FOUNDATION ft PROP R i[ <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH H DEPTH ft <br /> DISTANCE TO NEAREST WELL _ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY I HAVE PREPARED IS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> T "E LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> M MUM It A/NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2(19 1 953-7697 <br /> SIGNED ..L_ Cmc.-� TITLE � DATE /?=&—©� <br /> le, <br /> raj <br /> L Z2 <br /> gyro. <br /> \\ ' DEPARTMENT USE ONLY <br /> Application Accepted By J Cin �� 1 Date 'Z'I �Q Area Employee ID# <br /> Final Inspection BDate 6y ❑ SPEC[..*PP�RMIT-Approved by <br /> Character of Soil to pth o Ft c�Pit/Sump Soil+If haracter. <br /> COMMENTS ck 4' <br /> Q2 Pdl <br /> PE Received Amount Date Permit/ Invoice# ermitlD# <br /> Code INFO By Cas Remitted Service Rc uest# � <br /> 210 is < <br /> 9r y���,-�--fes <br /> 42-01-001 ONSITE WASTEWATER PERMIT <br /> 12/2102 <br />