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r <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET - STOCKTON CA 95202 - (209) 468-3420 <br />NON-KEFUNDABLE PERMIT L:FlLL (LUU) U0J-/0y/ FOR INSPECTIONS t PIRES I TEAR FROM UATE ISSUEI <br />JOB ADDRESS t i �i2L`c �Z CITY/ZIP <br />CROSS STREET APN a7/-Z�—a PARCEL SIZE <br />OWNER NAME PHONEC2 <br />OWNER ADDRESS r— CITY/STATE/ZIP <br />CONTRACTOR '+ C- PHONE O <br />CONTRACTOR ADDRESS ^^ n r CITY/STATE/Z1 <br />f ' <br />LICENSE OC -42 OC -36 OTHER = la , NUMBER `(L EXPIRATION DATE k O ZS <br />WATER TABLE DEPTH: <br />❑ PERC TEST # <br />TYPE OF WORK: <br />❑ NEW INSTALLATION <br />❑ REPLACEMENT <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />BUILDING PERMIT # LAND USE APPLICATION # <br />❑ REPAIR/ADDITION ❑ ENGINEER DESIG D /ALTERNAT <br />❑ OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />, <br />INSTALLATION WILL <br />SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL <br />� erne <br />�� �►.� W 1 N 011 <br />❑ OTHER <br />NUMBER OF LIVING <br />UNITS: <br />NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ <br />SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ TX PLANT <br />❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />❑ LEACHING CHAMBERSS <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST <br />WELL <br />ft Y TI <br />ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATI <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />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 />Final Inspection By Date ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS �ov—r, To �e kyla. a5t tohl Le f !e -z Z&i To Air= �tQ�z�(2 <br />c?C '3sscf.- 3 <br />a- <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />9/21/10 <br />MEN <br />������r. <br />�r���if <br />� erne <br />�� �►.� W 1 N 011 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />9/21/10 <br />