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ONSI-I-a: ASTE ATER 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) 953-76997 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 3 CITY/ZIP S L(X-4zs�I, <br /> CROSS STREET O APN 9 3 S PARCEL SIZE 11 <br /> /' b <br /> OWNER NAME yl(� a Z PHONE (CaQq� <br /> OWNER ADDRESS 0"`-��+� y(� p(Z� �/ � ,v CITY/STATEIZIP /r�✓ <br /> CONTRACTOR w If ` PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑LIC-42 ❑UC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED(ALTERNATIVE <br /> D REPLACEMENT n OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION O-Il <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> V--`SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑i 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 /> E, LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 /> Q SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Q DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTI HAT I HAVE PR ED 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 /> MINI M 4 Nt:�TICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 954-76p7 <br /> SIGNED TITLE CJ�� DATE <br /> 14A 12 <br /> CAM <br /> E IFl <br /> > DEPARTMENT USE ONLY EA THDEPARTMENT <br /> Application Accepted By. Date Date S a/ ZOZlO Area r� 11 1 Employee ID# DQ <br /> Final Inspection By f Date Jf'/ /Y ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS �1�0- `�l�b <br /> b&f � <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Request# <br /> yaaH 07s Elsa 5.'4-W. 0n 'L 1 <br /> 42-01 C* IDV n ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14118 <br />