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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 /> NON-REFUNDABLE PERMIT w�y�CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS N✓ CIn'/ZIP L, <br /> H <br /> /JJ <br /> • CROSS STREET ! L I�WqM (ri✓• APN ` - ^�I ^ O7 PARCEL SIZE o• 9'9 > <br /> 0 <br /> OWNER NAME R1 t7e <br /> 7,X PHONE rr'n <br /> OWNER ADDRESS r •�+ /I C[TY/STATE/ZIP C� <br /> CONTRACTOR �V -0:0 PHONE O <br /> n �f <br /> CONTRACTOR ADDRESS Pb l'0 x CnY/STATE/ZIP �f CST erJ y Q <br /> LICENSE KC-42 0-C-36 OTHER NUMBER 4`}/"G7'O'IfrEXPIRATION DATE /"P) ' <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: - NEW INSTALLATION REPAIRIADDITTON _ ENGINEER DESIGNED IALTERNATNE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM - DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LMNG UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CO A Gr�/3I'rAh CAPACITY I CQG y gal #OF COMPARTMENTS <br /> ❑ GREASETRAP TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> DISTANCE TO NEAREST: WELL / ft FOUNDATION J ft <br /> C J ft PROPERTY LINE a <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES I LEACHING CHAMBERS #OF LINES ^� LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL p C � • ft FOUNDATION C , ft PROPERTY LINE S ` ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft 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 NEA EST WELL it FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER WIDTH ita ft DEPTH S ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION� ft PROPERTY LINE S ft <br /> [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 /> MINIMUM 48 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 995J3-7)697 P <br /> SIGNED -49 TITLE DATE <br /> 40b— <br /> �i <br /> 46 <br /> � O10 <br /> Hry <br /> T <br /> EP TMEN SE JNLY <br /> Application Accepted B Date Area Employee]D# 9 <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to th of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS1 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> de INFO ash R itted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4114118 <br />