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r <br /> r C <br /> t' J ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN CCUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 05205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> FC11-1: <br /> ADDRESS CmrZIPSS STREETll APN 73� ty C 4+ r <br /> / PARCEL SQE <br /> a <br /> OWNER NAME <br /> PHONE <br /> OWNER ADDRESS CD'Y/STATE(ZP <br /> CONTRACTOR__eryScl:ll�}l���L—�/ l-�yPHONE_?,�1�%'SA/Z7 <br /> CONTRACTOR AonnE59y� e/Jfir`E�I7Y/STATFlLII) <br /> LICENSE _ fJ-38 OTHER NUMBER )7 EYPIRATION DATE �� f <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT$ LAND USE APPLICATION A` <br /> TYPE OF WORK: NEW INSTALLATION j>d,REPNR/ADomoN ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL I: OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPJMFG CAPADrrY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY <br /> pal #of COMPARTMENTS <br /> DISTANCE TO NEAREST: V/ELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFTSTATION S12:E TYPE OF PUMP Cl PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBERS ` f #DF LINES—,j__ LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL ft FOUNDATION '157-, it PROPERTYLINE Jf7� ft <br /> ❑ FILTER BED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH h LENGTH fl DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> SUMPS d X WIDTH N N LENGTH It DEPTH k/ ft <br /> DISTANCE TO NEAREST WELL ft FOUNCATION R PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE It <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTF; 8 <br /> DISTANCE TO NEAREST WELL R 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 /> UM 48 HQUR AQVAWEE REQUIRED FOR 1 ALL(209)9 7697, <br /> SIGNED TITLE �-- DATE G'c✓ ZC� <br /> S P - Pq yNIE <br /> FCF�VNp <br /> I II R 22 ?420 <br /> I i I q QUIN C <br /> 11 I C pqR MEjVTY <br /> �l DEPARTitENIgUSIE ONLY <br /> Application Accepted Py DateY11211'14)1:0 Area C Employee ID# J �K <br /> Final Inspection By Date L.;SPECIAL PERMIT-Approved by <br /> Character of Soli to Depth of 3 Ft Pit/Sump Soil Character: <br /> COMM11 IENTSC'Xish>t ' SYS/Flvl - ;r ,S IStln< A')#! (n%fC-'Ilm IVT• (: n oolj t <br /> rJ 1 'i6 v re I -T7kj <br /> VVIR <br /> nT /Pg2CLi <br /> PE SC Rece ed Ch-k#/ Amount Permit/ <br /> Code INFO B Cas Remitted Date Service Re nest# Invoice Y Permit IDA <br /> ��0 O <br /> 42A1 V J f�O �� <br /> 4,14118 NS ITE WASTEWATER TRTK rr SYSTEM PERMIT <br />