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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS � .2 .OXJh/ CITYIZIP )Ve-y <br /> CROSS STREET ASV-nhe ,/�'� APN Q� U -IO PARCEL SIZE Q- S� <br /> OWNER NAME_ f—�.fiw SCl3 S PHONE <br /> OWNER ADDRESS / CrrYISTATElZIP `f'6�2-C <br /> CONTRACTOR Llir�/iw'..ilyy/���� �///d��u0�� PHONE �G / �� / <br /> CONTRACTOR ADDRESS .YC AL. CITY/STATE/ZIP /e z <br /> LICENSE KC-42 C-36 OTHER NUMBER 777OSVS— EXPIRATION DATE 67-31-1V <br /> I <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> L PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: i-� NEW INSTALLATION REPAIR/ADDITION - ENGINEER DESIGNED/ALTERNATIVE <br /> G REPLACEMENT - DESTRUCTION <br /> INSTALLATION WILL SERVE: -RESIDENCE = COMMERCIAL D OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: S NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPEIMFG �SfJSh x'� CAPACITY le= gal #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL fl FOUNDATION It PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> Qi- LEACH LINES PL LEACHING CHAMBERS IO #OF LINES�_ LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION Jo It PROPERTY LINE It <br /> ❑ FILTERBED WIDTH ft LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTYLINE It <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH It LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELLIt FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE h <br /> SEEPAGE PITS NUMBER I WIDTH S ft DEPTH 2SJ ft <br /> DISTANCE TO NEAREST WELL I°Aft FOUNDATION a5 ft PROPERTY LINE Ip;;. It <br /> 1 HEREBY CERTIFY THAT 1 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE IZ. <br /> Vj <br /> mAYME <br /> _v D <br /> 13 VTI I <br /> 2N O MIT <br /> TRE U.T <br /> _..EPARTME T U ON ��A <br /> Application Accc/e Data � 2 Area Employee ID# / <br /> Final Inspectiotr B Date —7(o' ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to pth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PESC Received Check#/ Amount Date Permitf Invoice# Permit ID# <br /> Code INFO B Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 10/4107 <br />