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ONSITE WASTEWATER 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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 4' 1 ��t �4j. 1 CITY/ZIP L-`V-1 1GO -Z31 k <br /> H <br /> CROSS STREET 3V; APN C5:!� O Z '1� f�� PARCEL SIZE <br /> d <br /> " PHON �OWNER NAME 'r` <br /> i <br /> OWNER ADDRESS L- C' lw� C=;:�, CITY/STATE/ZIP <br /> CONTRACTOR_ L W- PHONE_ <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE _ C-42 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: �`Z ' ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I i NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT 1 OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: '`RESIDENCE ❑ COMMERCIAL _ OTHER <br /> NUMBER OF LIVING UNITS: �rNUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: Z/ <br /> SEPTIC TANK TYPE/MFG p / L CAPACITY T gal #OF COMPARTMENTS <br /> / U 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 /> LEACH LINES LEACHING CHAMBERS #of LINES <br /> - LENGTH OF LINES <br /> ft <br /> DISTANCE TO NEAREST WELL �0� ft FOUNDATION VS ft PROPERTY LINE <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE VIIJAr ft <br /> L3MOUNDED WIDTH ft LENGTH ft DEPTH R�' 1 ff <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE v(�I VEn ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY L w 40 ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH E IN I-p, ft <br /> DISTANCE To NEAREST WELL 2 ft FOUNDATION ft PROPERTY LI L7H I)apw TqL ft <br /> SEEPAGE PITS NUMBER 4� WIDTH / — �Q ft DEPTH lz �I TME 7' ft <br /> DISTANCE TO NEAREST WELL d V ft FOUNDATION *I�C­ 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 /> MINIMUM 48-HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> a <br /> c <br /> nG , <br /> Z' / D.EPARTMENT USE ONLY 4 l I q <br /> Application Accepted B � _ Date? odd 0 Area Employee ID# D� <br /> Final Inspection By Date 0 Za?� ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS 00 1'nFS ,f t}in 4v S In Lerh jo F i a ownet 4-o eI�rm <br /> 04-a— 3 0 V-41.3 CON tv -d��o <br /> PE Sc Received / Am unt Date Permit/ Invoice# Permit ID# <br /> Code INFO B Casl Remitted Service Request# <br /> Sao y�LOt7 3 <br /> 4 �,�s-��!�,d a X�'i ' '�.��(�..�r G►�s � <br /> A-_ �./y I / L ONSITE WASTEWATERR�TTRTMMNNT SYYSTEM(�PERMIT <br /> 4114/16 �� 11 1 ncl Y�' .i 1 1 KS"LLQ�' �� 3,6 o&f je 0'i�S<D-- 1- / 1/�-1 �� 0 <br />