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I <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> i SAN JOAQUIN COUNT)Er VIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AN'E-3"'FL-STOCKI'ON CA 95202 -1209)468-3420 <br /> ` NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE <br /> JOB ADDRESS J CIT\'/ZIP / r n <br /> CROSS STREET AJr✓uGL /e' APN V J 1-- �i'.,-7 / PARCEL SIZE +(� <br /> OWNER NAME PHONE <br /> OWNERADDRESS / ) 6,4 C�r 02937 CITI'/STATE/ZIP <br /> CONTRACTOR 'r')/"t/ 1�1t JIl�_�> L+X PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE AC-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: CoordinateS X Y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER ((�� <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: +1] <br /> SEPTICTANK TYPE/MFG1 � CAPACITY �. gal #OF COMPARTMENTS V <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS l <br /> L ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSEDSYSTEM) <br /> XLEACH LINES El LEACHING CHAMBERS #OF LINES LENGTH OF LINES --E�OSG/ ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION PROPERTY LINE :Z�Q11110 fl <br /> ❑ FILTER BED WIDTH fl LENGTH Ii DEPTH fl <br /> DISTANCETO NEAREST WELL ft FOUNDATION fl PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ti <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> him SEEPAGE PITS WIDTH G �/ it LENGTH ft DEPTH ft <br /> J ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION -j5�2:�L ft PROPERTY LINE fl <br /> 1 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 /> Illor MINIMUM 2 URA NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 , <br /> SIGNED TITLE DATE �� h <br /> J <br /> If <br /> (� <br /> do <br /> / � A <br /> ( <br /> n <br /> AN 3O L <br /> D P <br /> DEPARTMENT UYE O Y <br /> Application Accept I- Date Area -� Employee ID# <br /> 111111 Final Inspection Date ❑ SPECIAL PERMIT; proved by <br /> Character of Soil t t of Ft: 6. Pit/Sump Soil Character: / <br /> COMMENTS c c Xq� <br /> PE SC Received hec Amount Permit/ <br /> Code INFO B ash Remitted Date Service m uest# InNoice# <br /> Permit lD# <br /> � Zai 17 f�. • � / / Ism !�/ <br /> 11111110 <br /> 42-01-001 <br /> ��11— <br /> ONSITE WASTEWATER PERMIT <br />