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ONSITE"ovASTEWATER TREATMENT SYSTEM' rcRWIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 640 E MAIN STREET -STOCK70N CA NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS ExPIRES 1 YEAR F M DATE ISSUED k � JOB ADDRESS 1.0 LG CITYIZIP ly' GEOGRAPHICAL INFORMATION: Coordinate$ X Y ERC TEST # LEACH LINES BUILDING PERMIT # LAND USE APPLICATION # PE OF WORK: R NEW INSY n0N ❑ REPAIRIADDITION O ENGINEER DESIGNED IALTERNATIV6 0 /.., CROSSSTREET_%Lt,:Ttiv�4 _C 4Zt,�. ,,. APN a4S—fCf^ ! a� PARCELSUE G SER e OWNERNAME 9[ fA j`e /] :•• r-f� kur I&y^ Kj m --- PHONE NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPEIMFG CAPACrrV _ _ TYPEIMFG CAPACITY gal # OF COMPARTMENTS ^ OWNER ADDRESS 15 `o .1 i1(?/ Ci7YISTATEIZIP � b=—, A+ TYPE OF PUMP 0 PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) CONTRACTORLA4-19ak LO &W 6n el1['�Y{i.V{/�:1P,V�E PHONE �%�' ft FOUNDATION ft PROPERTY LINE ft l] li CONTRACTOR ADDRESS C&71(�I .y,^� I - ,/� C..A- I C • C17YlSTATFJZIP t0d • DEPTH ft UcENsV 4C-42 4038 OTHER NUMBER EXPIRATION DATE W RTABLE DEPTH: GEOGRAPHICAL INFORMATION: Coordinate$ X Y ERC TEST # LEACH LINES BUILDING PERMIT # LAND USE APPLICATION # PE OF WORK: R NEW INSY n0N ❑ REPAIRIADDITION O ENGINEER DESIGNED IALTERNATIV6 Q REPLA ENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INS LATION WILL SER ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER OF IFS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPEIMFG CAPACrrV gal # OF COMPARTMENTS D GREASE TRAP TYPEIMFG CAPACITY gal # OF COMPARTMENTS ^ DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft O LIFT STATION SIZE TYPE OF PUMP 0 PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) W I -L-Y- .. Application Acc9pted Bye Date. �S- O Area -EmplDyae ID# Final Inspection By / ate V 13 SPECIAL PERMIT - Approved by lJ Character of Sol[ toof 3 Pittsump Soil Character: COMMENTS PE SC Received Amount Data Pa IV Invoice # Permit IDN Code INFO Cash Remitted Service Re uest X I 42-01 - ONSITE WASTEWATER TRTMNT SYSTEM PERMIT �R 6rmm YY .. O LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH Or LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft C3 FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE k ^ O MOUNDED Wim ft LENGTH ft DEPTH H DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft l] li �. sumps WIDTH k LENGTH it DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft O DISPOSAL PONDS WIDTH ft LENGTH DISTANCETONEAREST WELL ft k FOUNDATION DEPTH It PROPERTYUNE ft ft C1 SEEPAGE PITS NUMBER WIDTH it DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE: IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, h STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. b F�: - ,-tc - -'�� -- -�'' 7LIE g ••, BOOP �•,°' ek C, ACC 4!AI 1 1209) 953.+7697 (ry SHINED , _ _ _ _ ITE nvr 33 • � Ike -• , z z Ei ! G I ..1j 7 _ RAM T e EI r -L-Y- .. Application Acc9pted Bye Date. �S- O Area -EmplDyae ID# Final Inspection By / ate V 13 SPECIAL PERMIT - Approved by lJ Character of Sol[ toof 3 Pittsump Soil Character: COMMENTS PE SC Received Amount Data Pa IV Invoice # Permit IDN Code INFO Cash Remitted Service Re uest X I 42-01 - ONSITE WASTEWATER TRTMNT SYSTEM PERMIT �R 6rmm YY ..