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In-,. <br /> 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_ _ CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 G F«�M n+t{ro^ �. CITYIZIP S+eck t1,7 C� `�> Zr s <br /> JOB ADDRESS � • <br /> ^L IF <br /> CROSS STREET COaA.Qt ) APN I T 3i ©03 PARCELSIZE 1•YZ 4t--Cf p <br /> OWNER NAME PHONE <br /> t �rom,-1 u <br /> yCA6 <br /> OWNER ADDRESS � .I Z u �n-- CITVISTATE/ZIJP 7)(rlL- C.�•tT �( <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS rL9-I)I ff_�^ l Z•''��t �'f `1 3^�h S <br /> k,Lt Io-o f/ CITYISTATEIZIP ^ C,/t' 4$- <br /> LICENSE C-42 I: C-36 OTHER O U63 ?{ NUMBER 96"V EXPIRATION DATE -22 -2 - Z�1'7 <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: .l RESIDENCE COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP (3 PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINEft <br /> p� <br /> ❑ FILTER BED WIDTH It LENGTH ft DEPTH iPAYu - ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN �._ ft <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH V n ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY Llfm"_iJJ---oe­­—ft <br /> 13SUMPS WIDTH It LENGTH ft DEPTH ! U ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY IOAI� _ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH HEA)Tu NMENTAL ft <br /> 8E�q <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE E} ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH 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 LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE RE UIRFD FOR INSPECTIONS--PLEASE CALL 209 953-7697 <br /> SIGNEDc,�h. =� TITLE �I��IU�-F �c(/w - DATE <br /> (3 <br /> Ufa• <br /> Eh <br /> O' xe A e <br /> OB-2 <br /> _ O P1 <br /> 0B-1 B-3 ®p3 <br /> {i tS <br /> i"�rrrTlrtc){�1� <br /> I <br /> ' 1 . <br /> � DEP RTMENT USE Q Y _ <br /> Application Accepted 8y��" 4 r - Date 2, C Area Employee ID# CC,!— <br /> �C <br /> Final Inspection By Date 1 SPE IAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS P1 f .1 <br /> PE SC Received Check#I Amount I Date Permit/ Invoice# Permit 10# <br /> Code IN O B Cash Remitted i Service Request# <br /> r _ ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> t P)1 <br /> 42-01 <br /> 4;24i12 <br /> l <br />