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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT 304 E WEBER AVE -3"'FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT jC'ALL(20y9))953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> c— <br /> JOB ADDRESS I r f f/ �y CITY/ZIP JP19` y N <br /> ­ � /� <br /> sCROSS STREET 19, APN �A Y/- /0 +yy�P`7A`RCEL r512E <br /> OWNER NAME 1y D l / 7 Iyfq/L/ PHONE <br /> , ONOWNER ADDRESS 7 / CoeC T rLrf CITY/STATE/ZIP / / <br /> aC <br /> 4 �• ` V� `" / <br /> CONTRACTOR Q`tiL h V tr 1 q 3013S3, PHONE <br /> CONTRACTOR ADDRP.SS CITYISTATE/ZIP <br /> LICENSE ❑C-42 Q C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) i~i'JMBSR LAND USE APPLICATION# -- <br /> TYPE OF WORK: x NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE _ <br /> ❑ Rr.PLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: V RESIDENCE ❑ COMMERCIAL j ❑ OTHER_ <br /> NUMBER OF LIVING UNITS: f NUMBER OF BEDROOMS; / NUMBER Or EMPLOYEES: <br /> 10 SEPTIC TANK TYPE/MFG C49 41 Lir�j' � _ CAPACITY /6 Q U gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCETO NEAREST: WELL ft FOUNDATION P PROPERTY LINE fl <br /> ❑ LIFT STATION SIZE TvPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> C / <br /> LEACH LINES ❑ LEACHING CHAMBERS J #OF LINES / _ LENGTH OF LINES 0 <br /> �^0 _ ft <br /> DISTANCE TO NEAREST WELL FOUNDATION 7- ft PROPERTY LINEy V tL <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH tt <br /> DISTANCE TO NEAREST WELL _ 11 FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH 11 LENGTH _ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 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 LAW RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOU VA ICE REQUIRED FOR INSPEC NS—PLEASE CALL(209)953-7697 <br /> 7/7 s <br /> SIGNED TITLES DATE Q <br /> g' <br /> I <br /> d <br /> G <br /> � t <br /> s r . <br /> ti, 44 IV A r <br /> .` <br /> r <br /> ' PQ IN CO <br /> BLS g4151Q <br /> `' . .' DEPARTMENT USE ONLY ` <br />` lA IIJ� r I` <br /> Application Accepte�By Date J '� , � Area �I14 Employee]❑#_Final Inspection By_ — Date �'��� r9� ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil trt h of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS Ll L••G <br /> PE SC ReceivedCheck#/ Amount Permit! <br /> Code INFO B as Remitted Date rvi uest# Invoice# Permit 1D# <br /> 4z in 3210 37 ra_3 Q 2 <br /> 42-01.041 <br /> 12/2JO2 ONSITE WASTEWATER PERMIT <br />