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PE <br />EX <br />PERMIT <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT �� <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (2099i6Y-�4Eo I RED <br />NUN-RCYUNUAt3Lt 1't KMI I <br />UALL LUJ J0J-/08/ I -UK INS/'tClIUNS tAPIKtS 7 TLAK FFKUM LJAI IJ,Ut <br />JOB ADDRESS�`� 1 I <br />�' l�`L✓'�Y76�- <br />LAND USE APPLICATION # <br />CITY/ZIP , �� c_* -i <br />_ NEW INSTALLATION <br />REPAIR/ADDITIONENGINEER <br />_ DESIGNED/ALTERNATIVE <br />It LENGTH <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />CROSS STREET ! 11 L r ✓Vl\ ✓� i <br />�� ` <br />APN <br />'060 G PARCEL SIZE /.6 <br />h <br />OWNER NAME L � <br />m �/ •�L C� <br />1%/-'- i <br />PHONE / LJ `t � - <br />4 <br />///--1 <br />OWNER ADDRESS �7 4-6� ( <br />( j L O >�/^ <br />,1� y 5' �/A <br />CITY/STATE/ZIP (Sy ✓'-✓ -1 ` � <br />C4 <br />DISTANCE TO NEAREST: WELL <br />/7Lf(/r <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />CONTRACTOR N,J.! <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />WELL <br />PHONE <br />ft PROPERTY LINE <br />CONTRACTOR ADDRESS <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />CITY/STATE/ZIP <br />ft DEPTH <br />LICENSE L C-42 Ll C-36 OTHER NUMBER EXPIRATION <br />J <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />P PERC TEST # <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />_ NEW INSTALLATION <br />REPAIR/ADDITIONENGINEER <br />_ DESIGNED/ALTERNATIVE <br />It LENGTH <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL SERVE: D RESIDENCE <br />COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG l-4 <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑I� C LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES <br />PEOMDISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />° WIDTH <br />It LENGTH <br />ft DEPTH <br />I <br />OM E D (STANCE 70 NEAREST <br />WELL <br />ft FOUNDATION <br />—• \ <br />ft PROPERTY LINE �� � <br />❑ MOUNDED WIDTH <br />ft LENGTH <br />ft DEPTH <br />It <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUMPS WIDTH <br />ft LENGTH <br />ft DEPTH <br />It <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS NUMBER <br />WIDTH <br />It DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />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 <br />REGULATIONS OF SAN JOAQUIN <br />COUNTY. <br />SIGNEIr _�192�teDVANqg <br />REQUIRED <br />FOR INSPECTIONS <br />TITLE .�"'� <br />- PLEASE CALL (209) 953-769 <br />DATE I -/ 2- 0 <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4114/18 <br />fir <br />ED <br />TY <br />NT <br />