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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 <br />NON-REFUNDABLE PERMIT CALL Z09 953 FOR INSPECTIONS ry.� r-AFIHhb I TLAHrHOmUAIt: M� IJW <br />JOB ADDRESS 1jfkc)/C. A� "E • CITYYMP 2' rVGc'V� 4pr z it <br />CROSS STREET ^3'1 1S LE 7 .may, AP L P3 26 y ✓ 3 / PARCEL SIZE •�• <br />OWNER NAME ` A t—%y f " T`A; • ` I� e' PHONE 1 +O) 5A2d_D S32- <br />OWNER ADDRESS 2-13.2 v c k Pj A ` D R ' CITY/STATE/ZIP a M1iICTO � C^ ' 1) L*4 <br />CONTRACTOR �,�E OAIL &eOr-Ii I&AjMC&TTAL- PHONE 30 1' 031 <br />CONTRACTOR ADDRESS 14 0'1 W. D A Y— S7 - CITY/STATE/ZIP`OtD) C� 41S V <br />LICENSE ❑I::IC-42 (DOC -36 OTHER C LG NUMBER 7-171 EXPIRATION DATE L4 ' 3o - 7-7- <br />WATER <br />Z <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />�C PERC TEST# <br />Z BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />❑ NEW INSTALLATION ❑ <br />REPAIR/ADDITION <br />❑ ENGINEER DESIGNED/ALTERNATIVE <br />WELL <br />I::) REPLACEMENT C.I <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />I::] DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />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 <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 />❑ LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />Elp� <br />FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />AY <br />��1171 <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />I4��w� <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />�� <br />(3 SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />ft PROPERTY LINE aSi4kr <br />3 <br />J 422 <br />ft FOUNDATION <br />DISTANCE TO NEAREST <br />WELL <br />❑ DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />IRQU/NC <br />O/yF OUIvey <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />E3 SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />ft <br />D`pG n�� <br />- "T � <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />Mew <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 />MINIMUM 4ff L40UH AU N(;L- IVU IIGL- HL- UIfYCu rvrr nvarct. r rv/vo - rr ciaac � -- cw - <br />SIGNED TITLE P��� • G t- • DATE <br />� lil <br />N00.07'04'W J30.01' <br />III F` <br />I,rN <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Depth of 3 <br />COMMENTS <br />S E <br />JONL /lill��� <br />rea 1 Employee ID# r>� <br />�I Irr I <br />❑ SP AL PAMIT - Approved by <br />Pit/Sump Soil Character: <br />PE SC Received Check # AmountDate PermiU Invoice# Permit ID# <br />Code INFO B Remitted, Service <br />Ret u+est/# <br />`7' ) <br />I I 1 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4114118 <br />