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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 ISSUEI <br />JOB ADDRESS O' /��/ � 1,71 CITY/ZIP <br />CROSS STREET TLr(Y 1. w yy'I�'1 ,,/(C�;C��APN 06 32 3 Z)L1 a PARCEL SIZE �• I <br />OWNER NAME S� (i yl ppl � C fdf )-10 PHONE <br />OWNER ADDRESS 121 t CITYISTATE/ZIP <br />CONTRACTORCtoll,'1�01 Vle CTAC PHONE on Q_3&Cl <br />_ 6� <br />IlCONTRACTOR ADDRESS 3 T71 k VI CITY/STATE/ZIP .J�(v(4 � 7l` <br />,­­'/ly <br />LICENSE 0,*42 C-36 OTHER NUMBER �iSSo�s ExPIRATION DATE 7 3 <br />WATER TABLE DEPTH: <br />I _ I 0 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />r <br />PERC TEST # <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEW INSTALLATInu X <br />REPAIR/ADDITION <br />_. ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMEN _ y , . .. ` <br />OUT -0F -SERVICE SEPTIC SYSTEM _ DESTRUCTION <br />INSTALLATION WILL <br />SERVE: XRESIDENCE <br />'... COMMERCIAL <br />D OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ <br />SEPTIC TANK <br />TYPE/MFG S�'t y <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />it FOUNDATION <br />fl PROPERTY LINE It <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES L10 fl <br />��T^ I �' <br />DISTANCE TO NEAREST WELL ��60 <br />It FOUNDATION <br />O'y ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH It LENGTH <br />ft DEPTH rt <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH It LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />fl PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH ft LENGTH <br />fl DEPTH It <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION <br />ft PROPERTY LINE It <br />❑ <br />DISPOSAL PONDS <br />WIDTH If LENGTH <br />fl DEPTH ft <br />DISTANCE TO EA EST WELL <br />It FOUNDATION <br />ft PROPERTY LINE fl <br />SEEPAGE PITS <br />NUMBER WIDTH —3/ <br />ft DEPTH 4P;J " ft <br />_�3 <br />DISTANCE TO NEAREST WELL /040/ It FOUNDATION /01 fl PROPERTY LINE 3G ft <br />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 />DEPARTMENT SE ONLY /, <br />Application AccepteH a L Date 1J /� Area y 9 `y Employee ID# FR <br />1` <br />Final Inspection BI _ Date l% l ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to DeP. , .r.: Ft: Pit/Sump Soil Character: <br />COMMENTS CX101n4 I-ec,Lk fiPICl to relvlccJh r d'x'iPd Sephi lf'lch (%ejjc cl <br />y^e�J rvod�l c'. �nF �ihE �r�iM n1�JsyS%Pmtt��,nLi2�1� it ne / mo[lvl�r h�rnP -- <br />Y X1 1irc. SYS e,r ori ok < ins ow(el eindJW /ice n)lt <br />PE I SC I Received Check#/ Amount Hermry <br />Code INFO I Bv. Cash Remitted Date Service Peputst # Invoice #_ Permit D# <br />M� <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4114118 <br />