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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 />P1UIN-r%tt-UNUAULt rtKMI I yI ALL LUbFY0J-/09/ hUN INW-tiIIUNJ CARIKt3 I T tAK t-KUM UAIt IJSUtL <br />JOB ADDRESS O �/ /(// C{ /!✓I CITY/ZIP <br />CROSS STREET S u /iL lly.rJl� AIN• S I ` P/ARRC,ELL SIZE �j �,(Z <br />OWNER NAME �n /V L,., Lr;Nei I�1L �/ Ir ti��l l�G PHONE '7yCJ -J1j -✓✓�� <br />OWNERADDRESS��-IJ /, /� /Llf �� / CITY/STATE/ZIP _�/(� iek I14! <br />CONTRACTOR 5 pT It�e- -5e ra ( (-C s 6, izo PHONE / y C/ �` z &� <br />CONTRACTOR ADDRESS / 0 6 ep K �6 �-/ �� L �CIITY/STATE/ZIP 4 Q . J G—A '?56 <br />LICENSE C-42 C-36 OTHER ",A NUMBER Ob FtOfp'tPIRATION DATE S �.� ZZ, <br />WATER TABLE DEPTH: <br />It GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # <br />BUILDING PERMIT # <br />LENGTH OF LINES <br />LAND USE APPLIC' , # <br />TYPE OF WORK: <br />NEW INSTALLATION la, <br />REPAIR/ADDITION) <br />. wiR DESIGNED (ALTERNATIVE <br />REPLACEMENT <br />OUT -0F -SERVICE SEPTIC <br />SYSTEM JTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE <br />COMMERCIAL <br />_R <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />AMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG t'T' kYl/ <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />- gal # OF COMPARTMENTS <br />MOUNDED <br />DISTANCE TO NEAREST: WELL <br />ft FOIRDATI/Nt <br />ft PROPERTY LINE ft <br />❑ LIFTSTATION <br />SIZE TYPE OF PUMP <br />O PKGTXPt j <br />0 SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />LEACHING CHAMBERS <br />SINES <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft Fr .TION <br />ft PROPERTY LINE <br />ft <br />FILTER BED <br />WIDTH <br />M LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />It ,DATION <br />ft PROPERTY LINE <br />It <br />MOUNDED <br />WIDTH <br />It LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />FOUNDATION <br />ft PROPERTY LINE <br />IT <br />SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />_ R FOUNDATION <br />It PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LEI R DEPTH ft 11 <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />11 SEEPAGE PITS NUMBER I ✓ / ft DEPTH <br />DISTANCE TO NEAREST It FOUNDATION / U f ft PROPERTY LINE Z - + ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS AP' , PION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE I SND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINIMUM 48 H CE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-769 <br />SIGNEDUl TITLE //,{' L- DATE '' --q }— E' <br />DEPARTMENT SE NLY q <br />Application Accepted By Date Area Employee ID# 7 S <br />A r <br />Final Inspection By s! Date Z SPECIAL PERMIT - Approved by <br />Character of Soil to pth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS �rc..o/� �l,cr�- vcry C../ - ,o.� /4,c lnn.�o/ !f- nPCf {� fPa�P� /���ia yll fv:f�tin <br />Z.C)o' <br />N --s Svl yS n 6, n. sS <br />PE I SC Received C eck#I Amount <br />Code INFO s Remitted Date <br />I/ ;L 10 1 / (S '300 z, <br />Invoice # <br />PermitID# <br />42-01 / ,) 1 / I � 1 -1 w � � D { U/��l$yif tQlq WgTER 7RTMNT SYSTEM PERMIT v� <br />4/10118 l �i�� rr �� l - 1 Ci a _G (/(/ l/ <br />