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r ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-HEFUNDABLE VERMIT (:ALL ZU9 YbJ-/69/ FOR INSPECTIONS CXPUMS l YEAR FROM DATE ISSUE[ <br />JOB ADDRESS { CTTY/LP r <br />CROSS STREE-r n„^ ! n APN O /% U -C 0 G ,5 �P/ARCELS. ��� <br />�OWNER NAME 4'� PHDNE-/4 7 #Qhe _ <br />OWNER ADDRESS S C, im rG 9 h -l' (./\._ CrTV/STAT.MP Gl <br />CONTRACTOR C 1(V �PHONE � / — �+ `T ✓� <br />CONTRACTOR <br />`ri�[ ADDRESS �U I �L+ O' ��C%"/ be. Ct7Y/STATE/ZJP /V A <br />ot— <br />LICENSE 11 YOTHER NUMBER .ir fU I EXPIRATION DATE / v <br />WATER TABLE DEPTH: 'L / ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />G <br />PERC TEST BUILDING PERMIT i LAND USE APPLICATION ai <br />TYPE OF WORK: NEw INSTALLATION A REPAIR/ADDITION <br />ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL <br />OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ <br />SEPTIC TANK TYPEIMFG 'D v[` CAPACITY <br />gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP TYPE/MFG CAPACITY <br />gal # OF COMPARTMENTS <br />DWANCETO NEAREST: WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />LIFTSTATION SIZE TYPE OF PUMP_ ❑ PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br />LEACH LINES LEACHING CHAMBERS #OFLINES <br />LENGTH OF LINES Y ft <br />r <br />DISTANCE TO NEAREST WELL It FOUNDATION (ffj0 , <br />ft PROPERTY LINE /' 40 ft <br />❑ <br />FILTER BED WIDTH ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL R FOUNDATION <br />ft PROPERTY UNE ft <br />❑ <br />MOUNDED WIDTH ft LENGTH ft <br />DEPTH It <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY UNE ft <br />❑ <br />SUMPS WIDTH ft LENGTH ft <br />DEPTH It <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH It LENGTH ft <br />DEPTH It <br />DISTANCE TO NEAREST WELL�7� ft FOUNDATION <br />ft PROPERTY UNE It <br />SEEPAGE PITS NUMBER WIDTH A/— ft <br />DEPTH ��S ft <br />/ <br />DISTANCETQ,NEAREST WELL 9(�/ / <br />� It FOUNDATION OCA � <br />q <br />R PROPERTY UNE _ �V ft <br />I HEREBY CERflFY THAT i HAVE PWARED 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 />Application Accepted <br />Final Inspection By . <br />Character of Soil toD <br />COMMENTS 1; <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />424/12 <br />