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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL. HEALTH DEPARTMENT 304 E WEBER AVE - 3- FL - STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPI JIF,$ 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS � � � CITY/ZIP b <br />=1 <br />CROSSSTREET' %ICN' ` APN ! �'" f zi — 5 PARCEL SIZE �'% � 1 <br />o <br />_ <br />� (�flaC-'t. �✓t''A'w� <br />ZV �7�z,,c`Lt <br />OWNERNAME CJR'3 PHONE 1 <br />1 1 I oG r l :5kjC <br />OWNER ADDRESS 4 GY CITY/STATE/ZIP C{/\ <br />/ <br />CONTRACTOR �'{'� L'/f / PHONE -]'32- C&O k� <br />+ <br />' <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE ❑ C42 ❑ C-36 OTHER —'L�F NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates % V' <br />❑ PERC TEST # BUILDING PERMIT # - UL 0 - LAND USE APPLICATION # -PA ,. C3- (,7(e <br />TYPE OF WORK: ❑ NEW INSTALLATION ❑ EPAIR/ADDITI ❑ ENGINEER DESIGNED /ALTERNATIVE <br />/i REPLACEMENT (11DESTRUCTION (4-67-14,/ 14- <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBEROF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />'1 /^� <br />SEPTICTAN'K TYPE/MFG *-L L SCC '� CAPACITY l7kcG gal # OF COMPARTMENTS_ <br />❑ GREASETRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE it <br />1� <br />�^ <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND 011. SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES <br />T <br />L <br />DISTANCETO NEAREST WELL JUT R FOUNDATION ft PROPERTY LINE ft <br />❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL fl FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED WIDTN ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERIY LINE ft <br />_ <br />❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br />4' <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />Z <br />❑ DISPOSAL PONDS WIDTH ft LENGTH it DEPTH It <br />t. <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br />/SEEPAGE PITS NUMBER WIDTH 6, i ft DEPTH 12 f <br />ft <br />DISTANCE TO NEAREST WELL l 7 S , ft FOUNDATION l it PROPERTY LINE ft <br />- REBY TIFYT9A HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY V' <br />ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINIM . 1 24 HOUR ADVANCE N01 ICE REQUIRED FOR INSP)NS - PLEASE CALL (209) 951-7697 <br />7- ✓`--A-�--�-� DATE <br />SIGNED TITLE <br />I a <br />f <br />ZEh- <br />P6,3 1� <br />O W I An <br />=41, DEPARTMENT U: E ONLY fq <br />7l US` Employee ID# <br />Application Accepted B Date Area <br />Final Inspection By Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth f 3 Ft: it/Sump Soil Character: <br />COMMENTS OL,4 Z c i L F AFC c%!!!J _ <br />PE SC Received Ch Amount Date PermiUInvoice# PermitID# <br />Code INFO B Remitted Service R uesI # <br />S0 4 0 5 4 Z (n ! r <br />z. r a c:3 3st t J <br />42-02 -00 1 ONSITE WASTEWATER PERMIT <br />12'22^_003 <br />