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Z1, <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET - STOCKTON CA 95202 - (209) 468.3420 <br />NON-REFUNDABLE PERMIT , ,CALL 209 953-7697 FOR -INSPECTIONS ,QEXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESSJAJ /zip <br />CROSS <br />CROSS STREET �(/V�LJ�C{�/J {7 C APN Z91 -) �'�`�PARCELSIZE!F <br />OWNER NAME ��%/ '^- ���r. PHONE & CE� <br />{//A �J / /-+1 <br />OWNERADDRESS G�� CITYISTATEIZIP <br />CONTRACTOR <br />D/Q I��(�� ®/5h� PHONE��J <br />CONTRACTOR ADDRESS / ® QO 7�- �/ CITY/STATEIZIP---!/� �/'• /) .�-' �� <br />LICENSE f C-42 _IC -36 OTHER NUMBER 5�95�5/EXPIRATION DATE 7 I L <br />WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: CoordinateS X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: 7 NEW INSTALLATION J REPAIRIADomoN ENGINEER DESIGNED �/AL'T-ErTIVE <br />.l REPLACEMENT J OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION � <br />INSTALLATION WILL SERVE: fl RESIDENCE ❑ COMMERCIAL - LI OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG CAPACITY gal # OF CO6IPARTMENTS <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 />V- <br />❑ LEACH LINES 1= LEACHING CHAMBERS # OF LINE= LENGTH OF LINES it <br />DISTANCE TO NEAREST NF_LL ft FOUNDATION It PROPERTY LINE ft <br />❑ FILTERBED WIDTH ft LENGTH_ R DcEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION z ftp"PROPERTY LINE ` <br />❑ MOUNDED WIDTH ft LENGTH ft DEPTH <br />DISTANCE TO NEAREST WELL It FOUNDATION it PROPERTY LINE ft <br />❑ SUMPS WIDTH ft LENGTH ft DEPTH It <br />DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH It LENGTH It DEPTH It <br />DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br />❑ SEEPAGEPITS NUMBER WIDTH it DEPTH <br />it <br />DISTANCE TO NEAREST 'NELL 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 />SIGNED <br />I <br />Appllcatlon accepted B �­;- <br />I <br />Flnal Inspection B/ - <br />Character <br />Character of Soil t of 3 F _ <br />COMMENTS M . <br />Code I INFO <br />O7 <br />42-01 <br />9121/10 <br />k Date _ <br />v � s <br />ear#d Amount Date <br />Is Remitted _ <br />s . col (d';—� I <br />TITLE DATE <br />F. SPECIAL PERMIT -Approved by <br />Character: <br />Service Request # <br />OO &/ (a •2-4 <br />invoice # Permit ID# <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />