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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOC KTON CA 95205 -(209)46"420 <br />JOB ADDRESS <br />CROSS STREET <br />-/out I-UK/NSPCC7lUNS rAPTKtSI TLAX I-KUM UAlt: 155Ut <br />( I ' CITYIZP�_r� <br />APN v -% i 070 vy PARCEL SIZE t� 1- <br />OMERNAME�)�V'I�-� I�VIijrL�� D31D7es, /r r �/L PHONE / <br />OWNER ADDRESS iJ O - Z.61 Ir CIN/STATE/ZIP <br />CONTRACTOR 1'_N' / VT L PH <br />/ ONE ��_✓ — �/ <br />CONTRACTOR ADDRESS 3 7y(Q� B� /44- r_CITY/STATE/ZIP <br />\ <br />LICENSE 142 C-36 OTHER NUMBER T/�jEXPIRATION DATE 13`� <br />WATER TABLE DEPTH: <br />PERC TEST # <br />TYPE OF WORK: <br />SO ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />BUILDING PERMIT # LAND USE APPLICATION # <br />NEW INSTALLATION REPAJR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL <br />SERVE: RE IDENCE <br />COMMERCIAPLI- p�,D_�OTHER <br />U <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: L3 NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG ge, fid my <br />CAPACITY gal # OF COMPARTMENTS <br />O GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />L LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />(\ <br />DISTANCE TO NEAREST WELL It FOUNDATION 740 ft PROPERTY LINE �f�� , ft <br />❑ FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />R FOUNDATION It PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH It <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH _ ft LENGTH <br />ft DEPTH R <br />SEEPAGE PITS <br />DISTANC ONEAREST WELL <br />NuMBER WIDTH <br />It FOUNDATION ft PROPERTY LINE R <br />.3 ---ft DEPTH i5 ft <br />` <br />DISTANCE EAREST WELL �.O <br />It FOUNDATION COO A R PROPERTY LINE UO R <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 />Application Accepted Date S �1r / Area I/ - Employee ILN lit <br />Final Inspection By Date v SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS 54j*2)2 , �Y— 1,1212 2 CJ 3 x , fs L ; P:10 o C line <br />PE SC Received Chet Amount D Permit) Invoice # Permit ID# <br />Code INFO h Remitted rvic a uest # <br />42-01�O / G� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14118 /fes V <br />