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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-MEFUNDABLLE PERMIT GALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS 1-VZZ 5. P�IEST �'b CITY/ZIP FXEAJC({ "MP %-Z-3(A- <br />CROSS STREET �p p-) / M A N APIN � � 3 � �'�� � � 2– PARCEL SIZE I . O AC . <br />OWNER NAME %XITTA &-0-L bj&jCr PHONE I72'rJ 2'7-3'--73 tO <br />OWNER ADDRESS P' 0 - FOX I 0 D I I CITY/STATE/ZIP C. LAKE -T Aft F- � CA <br />CONTRACTOR L -I V C 0^4 C C0 E AW % 1Z0 AIM EAT A L PHONE iZ or') 3(4y - 03 -7 �- <br />CONTRACTOR ADDRESS 14 V, w - 0 A k 3,T. CITY/STATE/ZIP L 0 D ( CA cf L4 V <br />LICENSE i L".',.0-42 11 C-36 OTHER C E NUMBER t S ( EXPIRATION DATE ` ` <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />�( <br />PERC TEST # BUILDING PERMIT # <br /># OF LINES LENGTH OF LINES <br />LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION <br />REPAIR/ADDITION <br />I''. ENGINEER DESIGNED/ALTERNATIVE <br />ft FOUNDATION ft PROPERTY LINE <br />REPLACEMENT _I <br />OUT -OF -SERVICE SEPTIC <br />SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: _! RESIDENCE <br />COMMERCIAL <br />_ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ <br />SEPTIC TANK TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP 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 />❑ <br />LIFT STATION SIZE TYPE OF PUMP <br />0 PKG TX PLANT <br />O SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />. LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH <br />Sd <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE <br />It <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE <br />It <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />It DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION 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 COUNTY. <br />48HOUR <br />QVANCE <br />NOTICEREQUIRED <br />FOR INSPECTIONS - PLEA ECALLt2O9)953-769 <br />SIGNED <br />TITLE n2OJ• SGA, • DATE <br />d G -I - 2 Z <br />'�NT <br />Y� <br />C,e.. _ <br />4lTDEPARTMENT U E ONLY <br />Application Accepted By ` Dt._y 7Area Employee ID# <br />Final Inspection By Date ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pi ump Soil Character: <br />COMMENTS O/V— 1'leyk �e e- <br />L°�'�mti �rG <br />PE SC I Received Check#/ I Amount D e PermiU Invoice # Permit ID# <br />Code INFO Cash Remitted Service Request # <br />2 i 22 0 <br />4 // � -� � L 77 2Q -3ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14//14/ 18 /�"LO/l�'l/. / <br />