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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SANOOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)4883420 <br /> MON-REFU rT CAL.I.(209-LS53-IMIYOR INSPECTION EXPIRES TE ISSUED i <br /> J08 ADDRESS CITYIZIP - • 1?n <br /> CROSS STREXkFaaAPN PARCEL SITE Y 16X <br /> OWNER NAME PHONE <br /> OWNER ADDRESSCITY/STATEJ2 P <br /> 46 <br /> CONTRACTOR L2 A- W <br /> �9 �0 fN�PHONE�,�r/�� � • <br /> CONTRACTOR ADDRESB A CRYISTATEIZIP <br /> LiceNse A-42 CC-36 OTHER , N UMB£RV�LEXPIRATION DATE <br /> I <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: COOrdinateS X Y <br /> D PERC TEST # BUILDING PERMIT# DO L LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION C REPAIRIADDITION ^ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT C DESTRUCTION <br /> INSTALLATION WILL SERVE: U RESIDENCE I MME L OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF EDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY t gal #OF COMPARTMENTS <br /> Q GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL' 'f ft FOUNDATION ft PROPERTY LINE <br /> O UFT STATION SIZE TYPE OF PUMP O PKG TX PLANT AND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> W LEACH LINES VLEACHING CHAMBERS #OFLINES LENGTH OF LINES C ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE J it <br /> Q FILTER BED WIDT I ft LENGTH ft DEPTH ft N <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Q MOUNDED WIDTH ft LENGTH ft DEPTH ft (� <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Q SUMPS WIDTHft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Q DISPOSALPONDS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Q SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL 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 /> =M1IM N ICE REQUIRED FOR INS C P S Ala (�09)953-TD�4►/� <br /> SIGNED TITLE Il <br /> I <br /> J I <br /> I <br /> i <br /> I <br /> 7 6 <br /> i <br /> 21 V <br /> EN <br /> JEAN <br /> ti I <br /> } <br /> I— <br /> rR N <br /> E <br /> I <br /> Rill <br /> r, I <br /> DEPARTMENT US O LY <br /> Application Acceptep,�y Date - Area Employee IDk <br /> Final Inspection 3, Date ❑ SPECIAL PERMIT-Approved by <br /> Character I Soil to pth of 3 : Pt/Sump Soil Character: <br /> COMMENTS OL/O "-r--6F ,2,£c--OW-4 f:;0 A- A)-9ca k"A 2• ,j6 1T42GELS �$Ou6uc"jscc— <br /> J S/T-E - S S r t -r ti D. 6 7ti <br /> E.✓E z <br /> At&F-,a d I I� <br /> PE SC Repetved Ch Amo nt Dat Invoice# Permit ID# <br /> Code INFO ash Remitted Service Re oast it <br /> 42,31 531 <br /> 42-01 ✓ �11111TEST �TITM.TYSTEM PERMIT <br /> 10/4107 <br />