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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />NUN-Rtt-UNUABLE rLKMI I <br />JOB ADDRESS I \ S2, <br />CROSS STREET I e.il n( kPl V G Ll APN— �A �PARCEL SIZE <br />OWNER NAME NI D \A'P. l'4 '� \ ��. �PHONE !7 % % / <br />OWNER ADDRESS ��, Q I Coir "a , 10we'l CITY/STATE/ZIP <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS CRY/STATE/ZIP <br />LICENSE ❑ _C-42 ❑'.. C-36 OTHER NUMBER EXPIRATION <br />D <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />❑ PERC TEST # <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEW INSTALLATION _ <br />REPAIR/ADDITION <br />I ENGINEER DESIGNED /ALT RNATNE <br />REPLACEMENT __ <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />Fs 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 ] ( j� gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />O 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 WELL <br />ft FOUNDATION <br />ft PROPERTYLINE ft <br />❑ FILTER BED <br />WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSALPONDS <br />WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft 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 />Z' <br />4 <br />m <br />0 <br />°a <br />v <br />DEPARTMENT SEONLY <br />t <br />Application Accepted By �� Date ) r Area " Employee]D# G <br />Final Inspection By �(. �&""k `� Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft:i�Character: <br />COMMENTS 15�1f J f }U f e „J CtS & i pi i5a(yJr' th o;1+ g.�f'vJ� r r t. Olo i c< ih 4 C ehiy <br />nr'1YVIt } it r _Stjo,' u!e ny7e-j SYDfrG TC,n�c'_ C;i%7 �/ouSf 4Ab. C l'pt"&,h5 <br />PE SC Received Check#/ Amount Dat Permit/ Invoice # Permit ID# <br />Code INFO B Cash Remitted Se ice Requer <br /># <br />a o7 Asa511-114 <br />4 1 C'C- `'' l/U ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14//14/ 18 V <br />