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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT ' <br /> SA.N JOAQULN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-RF.FUNDAB E _ CALL 209)953-7697 FOR INSPECTIONS _ I jEXPIRESI YEAR F Da SSUED <br /> .JOB ADDRESS CITY/ZIP <br /> CROSS STREET APN PARCEL SITE <br /> farX <br /> ^ <br /> C-0- NAME A CJ[� (��ty <br /> OWNER ADDRESS 1111�� 1 CITY/STATE 7 F C <br /> CONTRACTOR e \ivHv PHONE <br /> *1 VAN <br /> CONTRACTORADDRESS 'r CIT-VISTATE/ZIP 1 .P <br /> LICENSE -15� C42 ❑ C-36 OTHER_ NUMBER 'll EXPIRATION DATE <br /> �r,017 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST.. # I I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: , ❑ NEW INSTALLATION ❑ REPAIR/ADDITION X ENGINFEN DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: I ❑ RESIDENCE ' COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK- TYPE/MFG lCrrCAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPFIMFG CAPACITY _ gal #OF COMPARTMENTS <br /> DISTANCE To NEAREST: WELL `ft FOUNDATION - ft PROPFRTY LINE ft <br /> c <br /> ❑ LIFT STATION SIZE TYPE OF PUMP' '❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBE ICU #OF LINES 4 LENGTH OF LINEs V ft <br /> DISTANCE TO NEAREST WELL...1 M ft ' FOUNDATION �:40. R',.:—PROPERTY LINE R <br /> �❑ FILTERBED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LNE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft t1�1 <br /> DISTANCE TONEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WMTH ft LENGTH ft DEPTH ft O <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WMTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL' ft FOUNDATION ft' ' PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WmTH__ ft DEPTH R <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 <br /> RDINANCES,STATE LAWS AND RULES AND REGULATIONS OFOAN JOAQUIN COUNTY. <br /> NI. 2 a .E NOTICE REQUIRED FOR I. kS- E L(209)953-7697 rp�i <br /> SIGNE TITLE DATE 1 0 <br /> r <br /> 17 - <br /> r N <br /> E 17 <br /> - <br /> I <br /> es 6-r <br /> D - <br /> EM ENT <br /> ' <br /> '414 IF <br /> DEPARTMENT 1/jSE 9NLV i`-r=� c��7-s �•1 <br /> Application Accepted / Date �1 T, Area Employee ID# /37 <br /> Find Inspection By9pthof <br /> ' Date S ❑ SPECIAL.PERMIT-Approved by <br /> Character of Soil to 3 Ft: ItlSump Soil Character: <br /> COMMENTS 40 L.,o L_o7T o F 4-E�.2-4 DO N vT FI.J AL- S'EPTte �'EP �c,T U-tV71 l_ SO t L. Ai 17,G.¢`7-r- <br /> PE SC Received Checld#/ Amount Date Permit/ Invoice _ PermitID# <br /> Code INFO Cash Remitted Service Request# <br /> az-ol 7 S 9 u ' 1 5�ooT�l 5 0� L i F <br /> 05gO2ap7 Tcv- <br />