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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDA L P I ALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 AR FROM DATE ISSUED <br /> — — - — <br /> JOB ADDRESS _ �} CITY/ZIP . — <br /> CROSS STREET APN -- /-r <br /> PARCEL SIE 1 ,',:3 <br /> )119 CadttOWNER NAME PHONE o <br /> -,rJ�. M <br /> OWNER ADDRES f` 1`V'1/V ` ` ! CITYISTATE/ZIP �-/ <br /> CONTRACTOR '• -�- ! 1C�`�^ �'J+ �N�t �I jC..-PHONE 466 �/.0 <br /> CONTRACTOR ADDRES SR_3 1 A '�^ W CITY/STATE/ZIPr •V ' <br /> LICENSEC-42 1C-36 OTHER /' NUMBER -�` EXPIRATION DATE f <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y M - <br /> -- <br /> 1 PERC TEST # r BUILDING PERMIT# LAND USE APPLICATION# <br /> -- <br /> TYPE OF WORK: t.l NEW INSTALLATION REP AIWAUDITION I ENGINEER DESIGNED(ALTERNATIVE jam' <br /> I I REPLACEMENT OUT-Of-SERVICE SEPTIC SYSTEM ! DESTRUCTION i �l <br /> INSTALLATION WILL SERVE: 1 1-1 RESIDENCE 1_I COMMERCIAL ❑ OTHER 1 <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTICTANK TYPEIMFG Yff1Tl'I�C� - CAPACITY16CO gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE ft j <br /> a❑! LIFT STATION SIZE TYPE OF PUMP n ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) �O <br /> yp LEACH LINES LEACHING CHAMBERS+ 2-_ #OF LINESLENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL (Mj ft I-UUNOATION_ ft PROPERTY LINE 0 ft <br /> FILTER BED WIDTH it LENGTH It DEPTH <br /> DISTANCE TO NEAREST WELL f1 FOUNDATION It PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH it LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> SUMPS WIDTH �ft L N _ /( J ft DEPTH ft <br /> DISTANCE TO NEAREST WELL � ft FOUNDATION , It PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> J SEEPAGE PITS NUMBER WIDTH ft DEPTH It <br /> DISTANCE TO NEAREST VlELL It FOUNDF�TION ft PROPERTY LME $ <br /> 1 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 REGULAITONS OF SAN JOAQUIN COUNTY. <br /> 4.H RA@y4N9g#QT1REQUIRED FOR! TIONS-PLEASE CALL 209 953-7697 <br /> SIGNE TITLE DATE ) <br /> 40 <br /> nMon.CA 951,112 <br /> i <br /> G , <br /> L f2z�z!L• Y <br /> DEPARTMENT USE ONLY ��% y <br /> pplicaUon Acce ]t . Date J # <br /> Area� Employee ID#.5"TT� <br /> Final Inspection'8 ll ', -- Cc .� Date SPEC AL PERMIT-Approved by_ <br /> Character of Soil toibeplh of 3 Ft: Pit/S6mp Soil Character: <br /> ;OMMENTS 1J(t� QA-A,��c u��2��1���w I /11,ke)) <br /> PE SC Received heck#! Amount Date PermiU Invoice# Permit ID# <br /> Code INFO B Remitted Service Request#Ab _ <br /> - 1---- - <br /> 2-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> yt11110 <br />