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t <br /> `J ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM PA TE ISSUED <br /> JOB ADDRESS l 01r II z L"� i'1 CITY21P J7 C b <br /> "74- <br /> CROSS STREET �.p7.�J(`Y�A-��` APN �i,a 9— ll D r, P EL SIZE .>�O A��° > <br /> OWNER NAME L�2 PHONE o <br /> OWNER ADDRESS CITYISTATE/Z <br /> CONTRACTOR ,J n S PHONE <br /> CONTRACTOR ADDRESS (, <br /> t�C� 5.7.?CITYISTATEMP 9 <br /> LICENSE FC-42 11C-36 OTHER NUMBER IJ 7LW EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATI Coordinates X Y 0 u 1 <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER 10SIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ R IDENCE COMMERCIAL ❑ OTHER <br /> yyy NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: �J <br /> {Q SEPTIC TANK TYPE/MFG CAPACITY�� gal #OF COMPARTMENTS 'y <br /> LU` GREASE TRAP TYPEIMFG CAPACRY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBERS 4-- #OF LINES LENGTH OF LINES,A20 ft <br /> DISTANCE TO NEAREST WELL,16't It FOUNDATION R PROPERTY LINE it <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION—ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH it DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE it <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <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 /> MINIM M 24 H U D CE OTICE REQUIRED FOR INSPECTIONS PLEASE CALL 209 953-7697 <br /> SIGNED TITLE Dh O!• DATE > •3 - �- <br /> e r <br /> J• A. <br /> EPARTMENT S Ej 0 N L Y <br /> Appl(catlon Accepted B Data ea empiDye6lDi S!" <br /> Final Inspection By ate LJ SPECIAL PERMIT-Approved by <br /> Character of Soil to tt1 of 3 Ft: ump Soil Character: <br /> COMMENTS efY,,�Q <br /> PE ft <br /> ved LChec_ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Re uest# <br /> r <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 9121/10 <br />