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0 <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-rct1-unUAt1Ltf `tNMl l L ALL (LVYJ VOJ-10.41 FOR INSPECTIONStXPIRE_S 7 YEAR FROM UATE ISSUE <br />JOB ADDRESS 9 Li —I I� Y"Y�MU� J'J t� CITY/ZIP 5 I T oc IL (7J✓I 1 54-0 5 <br />CROSS STREET • ' T APN I _I 3 1 �( O " I PARCEL SEZZ7E r 3 <br />OWNER NAME ,� TV �I C V�: �%Z2 I I = PHONE <br />OWNER ADDRESSy onnck `t t: N� r U � CITY/STATE/ZIP .S I O i_ 1L. t -U ✓1 <br />CONTRACTOR LN PHONE Z n 4 — i O I <br />CONTRACTOR ADDRESS Cc) Q o r- I L-`3 1 CITY/STATE/ZIP G "I cl rl 7 V <br />LICENSE Li -IC -42 IC -36 OTHER NUMBER v EXPIRATION DATE G / 36 <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />-1 PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIRIADDITION I ENGINEER DESIGNED /ALTERNATIVE <br />7. REPLACEMENT OUT -0F -SERVICE SEPTIC SYSTEM ),' DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE . COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal #OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />it FOUNDATION <br />It PROPERTY LINE ft <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 ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />fl DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />fl FOUNDATION <br />ft PROPERTY LINE AOA%ea­ ft <br />❑ MOUNDED <br />WIDTH <br />(t <br />LENGTH <br />Il DEPTH �� ft <br />DISTANCE TO NEAREST <br />WELL <br />(I FOUNDATION <br />G (l <br />it PROPERTYLINE <br />❑ SUMPS <br />WIDTH <br />fl <br />LENGTH <br />ft DEPTH vC�; ft <br />DISTANCE TO NEAREST <br />WELL <br />fl FOUNDATION <br />ft <br />ft PROPEaw� <br />J <br />❑ DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />It DEPTH f QUl ft <br />DISTANCE TO NEAREST <br />WELL <br />(t FOUNDATION <br />It PROPER T*for Nr �, ([ <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTHfNl ft <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />(t 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 />DEPARTMENT USE ONLY ry�� <br />Application Accepted B G Date Id 8 .2 / Area C � Employee ID# / / tJ <br />Final Inspection ey 1'"� T , '� Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS prcrey soeVaFOr�1l/LLl �1n InC/ v G��GICe41Info <br />PE SC Received Chec Amount Permit/ <br />Invoice # Permit ID# <br />Code INFO B Date ash Remitted Service Re uest # <br />3a� j;S- Isa 0 -Z$ -2l S <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4114118 <br />