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u <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS F"as hr rel • FO -r <br />CITY/ZIP ��- .�) S Z <br />CROSS STREET <br />APN PARCEL SIZE Q <br />(� <br />OWNER NAME �� eL V�, �j1 �'�l/{�i C.� <br />�I: (. % PHONE 21ri y I G <br />jLt�r`pl--lin <br />��`��:Y' <br />OWNER ADDRESS `'f rl / J �✓I'iC Z'JS /'-'tel J -i` <br />,�A)L> <br />CITY/STATE/ZIP Y�r'14 7�7-L%✓I �.A OLYAC' <br />CONTRACTOR <br />PHONE <br />CONTRACTOR ADDRESS <br />ATATE/ZIP <br />LICENSE LJ C-42 .- C-36 OTHER 0 <br />ATION DATE <br />WATER TABLE DEPTH: ft GEO_.„� I <br />OR O"S X Y <br />C PERC TEST # BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION <br />REPAIR/ADDITION ENGINEER DESIG ED / l RNATIV <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: I.: RESIDENCE <br />I COMMERCIAL L OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION It PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ FILTER BED WIDTH ft LENGTH <br />It DEPTH ft <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNYY ERAR- ft LENGTH <br />ft DEPTH ft <br />ST WELL <br />ft FOUNDATION It PROPERTY LINE ft <br />❑ SUM1, STT ft LENGTH <br />ft DEPTH ft <br />1 E E WELL <br />Exp <br />It FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS IDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH It <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE It <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 REGULATIONS <br />OF SAN JOAQUIN COUNTY. <br />REQUIRED <br />-7697 <br />SIGNE , ! I� <br />TITLE DATE l'���� <br />V, <br />0 <br />0 <br />a <br />Character Of Soil ��D�eppt''h yOOff �3 FF,tt: Pit/Sump Soil Character: <br />COMMENTSr ” IN <br />4114neCU/l�(� � 1b 001 <br />