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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> .Sail JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 E , HAZELTON AVENUE - STOCKTON CA 95205 w (209) 468w3420 <br /> N <br /> NON-REFUNDA <br /> /BLE PERMIT -7� (C, ALL (209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> J <br /> JOB ADDRESS _ , / tJ KI'i l l_(,�t�� _ ! n4 _11' CITYY4z1P C-� S q') <br /> / � �1 <br /> CROSS STREET �`� C -L^ 1 �D't1-- /1-�� ,-{APN -I L� PARCEL SIZE [ v o <br /> OWNER NAME4''•4 •LPHONE '� J <br /> I ` � '� ' C' <br /> J L G ] / _ r � r J <br /> OWNER ADDRESS ` - 4l) .J J` Dk2i rt %I G .hl •7 �I 4 IOAITY/STATE/ZIP (r :x) � C-✓ 1/ <br /> � ,7• �L ) <br /> CONTRACTOR � ) !\ C �) ( i.r_ . llL.i ��_�,� ' c C.-_S PHONE _ : L` C-r • l L� lT t-y` :� C ` J <br /> CONTRACTOR ADDRESS _ V �',•�. CfTY/STATE/ZIP <br /> LICENSE 0 C-42 ❑ C-36 OTHER NUMBER ��' l� `� �� EXPIRATION DATE <br /> WATER TABLE DEPTH: L _ It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PT PERC TEST BUILDING PERMIT # _ LAND USE APPLICATION #. <br /> TYPE OF WORK: & NEW INSTALLATION REPAWADDITION ENGINEER DESIGNED /ALTERNATIVE <br /> 1 I REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE : W4ESIDENCE 0 COMMERCIAL 0 OTHER _ <br /> c,�- NUMBER OF LIVING UNITS : NUMBER OF BEDROOMS : J NUMBER OF EMPLOYEES: <br /> y SEPTIC TANK TYPE/MFG T +- 1.-, CAPACITY J-a�t-aQ_- gal # OF COMPARTMENTS <br /> ❑ GREASETRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL .,y • f It FOUNDATION 131 It PROPERTY LINE f( <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br /> EACH LINES LEACHING CHAMBERS # OF LINES 3 LENGTH OF LINES ` � � I It <br /> DISTANCE TO NEAREST WELL I ' It FOUNDATION Fj It PROPERTY LINE <br /> 3 / It <br /> ❑ FILTER BED WIDTH It LENGTH ft DEPTH S If <br /> DISTANCE TO NEAREST WELLIt FOUNDATION It PROPERTY Laf "." � ft <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH ` \ Ic It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY yI n it <br /> ❑ SUMPS WIDTH ft LENGTH It DEPTHQQ�� �� �� 2Q fl <br /> DISTANCE TO NEAREST WELLIf FOUNDATION ft PROPE�ATI d DAQ nA If <br /> ENV IRO FA I N� <br /> ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH kEz _. NMEw; It <br /> DISTANCE TO NEAREST WELLIf FOUNDATION _ _ It PROPERTY Lt EDEP'MrME1J It <br /> W'SEEPAGE PITS NuMBER 3 WIDTH It DEPTH a 51 It <br /> DISTANCE TO NEAREST WELL1j_ It FOUNDATION �_A I It PROPERTY LINE � I It <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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE-�;(I��C�'- � -F6 � DATE 4- l (✓• 17 <br /> Tc f I e <br /> tit aVL <br /> ' <br /> I <br /> OF <br /> FPO <br /> OF w <br /> O <br /> 1 <br /> "EPARTMENT O LY <br /> Application Accented <br /> /Qy % Date Area / Employee ID# <br /> Final Inspection By — Date � 'L fJ SPECIAL PERMIT - Approved by <br /> Character of Soil to eplh of 3 Ft: ..y Pi urn /Solt Character: <br /> COMMENTS [ ; r- t 't'� _ Qb i^ 640 <br /> PE SC Received tCheco" Amount Permit/Code INFO By _ -Cash emitted Date Service Request # Invoice # Permit ID# <br /> 4201 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4!241 i 2 <br />