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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER Avu - 3N° FL- STOCKTON CA 95202 - (209) 468-3420 <br />NUN-KEFUNDABLEYERMIT I,ALLILOY Y13-7DY/FOR INSPECTIONS LJCYIKENI YEAR FROM DATE ISSUE, <br />JOB ADDRESS 6 tl A -v"a Q K d 4 vc CITY/ZIP S+KV 75,2ts' <br />CROSS STREET RQ IV APN J 0�0 4 �PARCELL SIZE / to ,• <br />OWNER NAME I"., t \ 0 S � A PHONE /j' 3 <br />OWNER ADDRESS 316- e- k td.r v Q n J A U c CITY/S'IATE/ZIP S f %\ d / 5. <br />I�Q <br />CONTRACTOR /7 0 i/N�-Q &I �1 ON <br />PHONE <br />D <br />CONTRACTOR ADDRESS <br />r <br />LICENSE ❑ C-42 <br />❑ C-36 (MIERNUMBLR <br />EXPIRATION DATE 76 <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />❑ <br />PERC TEST # <br />BUILDING PERMIT #_ LAND USE APPLICATION # <br />TYPE OF WORK: <br />❑ NEW INSTALLATION REPAIR/ADDITFON <br />❑ ENGINEER DESIGNED/ALTERNATIVE <br />❑ REPLACEMENT ❑ DESTRUCTIONF <br />_ <br />INSTALLATION WILL SERVE: V RESIDENCE LJ COMMERCIAL <br />El OTHER <br />NUMBER OF LIVINC UNITS: NUMBER OF BEDROOMS: <br />NUMBEROF EMPLOYEES: <br />❑ <br />SEPTIC TANK <br />1I <br />TYPE/MFG X S f _ CAPACfrY -_ <br />gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP <br />TYPE/MFG CAPACITY <br />gal # OF COMPARTMENTS <br />❑ <br />PKG TX PLANT <br />DISTANCETO NEAREST: WLl-L it FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />❑ LEACHING CHAMBERS # OF LINES <br />LENGTH OF LINES <br />DISTANCE'rO NEAREST WELL. O O R FOUNDATION (a <br />_ ft PROPERTY LINE O <br />R <br />❑ <br />FILTER BED <br />WIDTH ft LENGTH it <br />DEPTH _ <br />fl <br />DISTANCETO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED <br />WIDTH _ _ft LENGTH _ft <br />DEPTH <br />ftr <br />DISTANCE TO NEARES r WELL it FOUNDATION <br />ft PROPERTY LINE <br />it <br />❑ <br />SUMPS <br />WIDTH ft LENGTH —D <br />DEPT "H <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION _ _ <br />ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH _ fr <br />DEPTH <br />it <br />DISTANCE. TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />R <br />❑ <br />SEEPAGE PITS <br />NUMBER % WIDTH Q h <br />DEPTH -? 5� <br />ft <br />DISTANCE TO NEAREST WELL D a _ R FOUNDATION (] ft PROPERTY LINE 3(D ti <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND'[ HE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br />ORDINANCES. STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />M Nimu 24 OU )VANC No riCE REQUI RFD FOR INSPECTIONSy7 PLEASE CALL (209) 953-7697 (� Q <br />SIGNED TM,F. 0 I l r Q[E F'Oc DATE �- 7 G/ <br />Application Accep7� <br />Final Inspectloo B <br />Character o9 Soil to Dth of 3 Ft: <br />PE SC Received <br />Code P. <br />BY <br />ZiO t6 <br />i <br />J <br />_ PARTMENT .-EO -V <br />Dale Area Employee IDN <br />Date IVIU&Q SPECIAL PERMIT - Approved by <br />Pi Sump Soil Character: <br />X, !/Z Vis <br />Amount Date <br />I L, I S2-1 0, <br />Invoice # I Permit ID# <br />42-02-001 ONSITE WASTEWATER PERMIT <br />