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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN SYREET-STOCKTON CA 95202-(209)468-3420 <br /> JON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1,. <br /> Joe ADDRESS ' - 5 - ( CInIZIP ss S r.- <br /> ' 7 y <br /> GROSS STREET 2� PARCEL SIZE 2- <br /> APN -2 <br /> p <br /> 1 0 <br /> OWNER NAME. lam.S'- f•s5 1' (`i�1 t�� k'- �f PHONE ' <br /> N <br /> N <br /> OWNERADORE53 4 . t:{: �. = C17YISTATEIZIP C.�.- X4.5 i.Z•C� <br /> 1 a <br /> CONTRACTOR \:.:' �•� PHONE '7 <br /> CONTRACTOR ADDRESS �S— L ). .,•- '....-- _rCITYISTATEPZIP ec- <br /> LICENSE 11C-42 ❑C36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> 97, �T <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DEsTRucnoN <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER Of LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> Q SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS •., <br /> Q GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE $ <br /> �i <br /> Co LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) (i <br /> O LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> I DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> (3 FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 0 MOUNDED WIDTH it LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE ft <br /> O SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> O DISPOSAL PONDS WIDTH it LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 0 SEEPAGE PITS NUMBER WIDTH ft DEPTH It <br /> DISTANCETO NEAREST WELL - A FOUNDATION ft PROPERTYLINE ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL PEPONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />' STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> I MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED i 7 <br /> _ __ i ..�..�-.-•._...s..-.:j�_____' TITLE l_r ... I .., 1�—�•'y� t PATE �T� i <br /> t' ( <br /> r <br /> c. <br /> e r <br /> Nil <br /> if. I i E I a �p T <br /> N! i I <br /> / f, J DEPARTMENT USE OlI A // <br /> Application Accepted By \ (rflt.° _ �!f•- r Data %I f�A"f Area Employee 1D# <br /> a <br /> Final Inspection 13y Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil CharaMer: <br /> COMMENTS <br /> PE SC Received 'Cheek#! , Amount Permit! <br /> Code INFO B Cash Remitted Date Service Request#17 <br /> Invoice# Permit ID# <br /> 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 10!4107 <br />