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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 <br />NON-REFUNDABLE PERMITC LL 209 953-7697 FOR INSPECTIONS EXP <br />IRES 1 YEAR FROM DATE ISSUED <br />Jos ADDRESS Y=lc " CITY/ZIP <br />CROSS STREET 1T/ /".fP r--� p APIN `-' �22'`�2 PARCELSIZE U 3r <br />OWNER NAME �FN`� `�NC� PHONE <br />OWNER ADDRESS CITYISTATEJZIP <br />CONTRACTOR ���// '(/K �' �- �"`�� r PHONE S�7/ 5- - yr -z , �^ <br />CONTRACTOR ADDRESS �7r% / ����%� ��' ��' CITY/STATEMP !�"'�(� ��- 51-31-r <br />LICENSE U C-42 ❑' C-36 OTHER �_ NUMBER EXPIRATION DATE ��� 2 .2 :-, 2 <br />WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # <br />TYPE OF WORK: <br />I I BUILDING PERMIT # <br />NEW INSTALLATION fV <br />REPLACEMENT <br />LAND USE APPLICATION # <br />REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: ® RESIDENCE <br />❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: 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 />TYPEIMFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: W ELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />OF LINES a ft <br />❑ <br />LEACH LINES <br />Aill!" LEACHING CHAMBERS <br />-?— # OF LINES <br />LENGTH <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION -3'-45 <br />ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH ft LENGTH <br />R <br />DEPTH It <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH R LENGTH <br />it <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH It LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />TI PROPERTY LINE it <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH <br />ft <br />DEPTH it <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />it PROPERTY LINE ft <br />SEEPAGE PITS <br />NUMBER --;IWIDTH <br />-31 <br />R DEPTH —_ ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />CERTIFY THAT i HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />1 HEREBY <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MWWUM 48 <br />SIGNED <br />"M ADVANCE NOTICE REQUIRED <br />EPR INSPEC77ONS - <br />TITLE"�� <br />PLEASE CALL 1209) 953-7697 <br />DATE Z 2 J ZJ c <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Depth of 3 <br />COMMENTS <br />1$9 ONL <br />' l� <br />7-9rea � �' Employee ID#� <br />0 SPECIAL PERMIT -Approved by <br />Pit/Sump Soil Character: <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14!18 <br />