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+fir <br /> 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 �') ?s7 ��cy.,v /��-�_ 0573-00 <br /> � CITY/ZIP <br /> CROSS STREET /lJti 'e:_(f APN 05 3-v/)I/O O(P PARCEL SIZE vo-oo <br /> p <br /> OWNER NAME '��YJvy �1��/l/yrS PHONE�S(j" <br /> rn <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONE 36 -S07_7 <br /> CONTRACTOR ADDRESS i CITY/STATE/ZIP <br /> LICENSE 11Pt-42 ❑1 C-36 OTHER NUMBER� EXPIRATION DATE G) / <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I I NEW INSTALLATION + REPAIR/ADDITION I ENGINEER DESIGNED/ALTE ATN <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM __< DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL './ OTHER p/ J <br /> Lst <br /> NUMBER OF LIVING UNITS: ,. � NUMBER OF BEDROOMS:t)"M�Y J NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY^61 1 v 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 PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> - --------- -------------- --- - ------------ <br /> LEACH LINES I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ' ft <br /> DISTANCE TO NEAREST WELL � ' ft FOUNDATION 16'0 ft PROPERTY LINE /L>(J 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 ft DEPTH ft <br /> DISTANCE TO NEAREST 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 ft <br /> I - SEEPAGE PITS NUMBER WIDTH 3 L' ft DEPTH ,�$ ft <br /> DISTANCE TO NEAREST WELL 1Ct7 ft FOUNDATION /GYM ft PROPERTY LINE le;r,' 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 HOUR ADVANCE NOTICE REQUIRED FR IN PECTION - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE/� iY�.L DATE <br /> /R N <br /> QAA�,,�,���� EPARTMENT USE ONLY �Fpq�HT,q��• <br /> Application Accepted y4vv`^aLD�� Date Y- �i- Area / I Employee ID# tiIF T <br /> Final Inspection By 11111"_ ka fL Date 11 SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS �( (�Qf <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> p- <br /> 42-01 <br /> iv Il5 300 $ 13 o VU 3` <br /> 'x.2330 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/16 <br />