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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE-STOCKTON CA95205 - (209) 4683420 <br />NUN-KEFUNDAHLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE <br />I' <br />JOBADDRESS �g7�L1—j 1�� C I np 2t+ Crn�zIP Lica:>,'�D, �SR;W <br />CROSS STREET I�'�!','�. V 1� \fJ' e /�;�J fie,. -'y AP <br />N ©I U .7 V 3D s PARCEL SIZE <br />OWNER NAME Fo�lr.!,,111r � 1'i/ 14��+i`11i C"n l l "� ti., �l, PHONE -I fC} <br />OWNERADDRESS LIDO -1 IC -1 Acct,"', �n CrrY/STATE21P !'\G{%�: �3YiO, CAS 'Cl]; a?„o <br />Dr � M0 �. <br />CONTRACTOR I:. /O�l `.1141. 7`�L, `. PHONE -,j9 <br />CONTRACTOR ADDRESS �(,i `1V"� fJC�i"l%�SG\Ll' ^ CITY/STATEIZIP <br />LICENSE ❑2C-42 ❑�C36 OTHER ICU, NUMBER LI�Z-1-I ExPIRATION DATE <br />WATER TABLE DEPTH: <br />.%•�i.� 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 />REPAIRIADDITION <br />❑ ENGINEER DESIGNED /ALTERNATIVE <br />DISTANCE TO NEAREST <br />SUMPS WIDTH <br />F' REPLACEMENT 11 <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />Il DESTRUCTION <br />INSTALLATION WILL <br />SERVE: 11 RESIDENCE <br />FJ COMMERCIAL <br />El OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />❑ <br />NUMBER OF EMPLOYEES: <br />❑ SEPTICTANK <br />TYPE/MFG <br />CAPACITY <br />gal #OFCOMPARTMENTS <br />❑ GREASE TRAP <br />TYPEIMFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />El LIFTSTATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES ❑ LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES ft <br />❑ <br />❑ <br />DISTANCE TO NEAREST <br />FILTER BED WIDTH <br />DISTANCE TO NEAREST <br />MOUNDED WIDTH <br />WELL <br />ft LENGTH <br />WELL <br />ft LENGTH <br />ft FOUNDATION <br />ft FOUNDATION <br />ft PROPERTY LINE i <br />ft DEPTH ft <br />ft PROPERTY LINE At <br />R DEPTH <br />13 <br />DISTANCE TO NEAREST <br />SUMPS WIDTH <br />WELL <br />ft LENGTH <br />ft FOUNDATION <br />ft PROPERTY LINE SA <br />ft DEPTH -- �� <br />❑ <br />DISTANCE TO NEAREST <br />DISPOSAL PONDS WIDTH <br />WELL <br />ft LENGTH <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft DEPTH ft/ <br />❑ <br />DISTANCE To NEAREST <br />SEEPAGE PITS NUMBER <br />DISTANCE TO NEAREST <br />WELL <br />WIDTH <br />WELL <br />ft FOUNDATION <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />- DEPTH ft <br />ft PROPERTY LINE ft <br />I HEREBY <br />CERTIFY THAT 1 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 RAN _MA -11 rn11— <br />-• uate U SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />7- <br />1412- <br />-1 <br />- <br />1412i <br />42-01 <br />aitarla <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />r <br />