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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDA L P IF CALL 209 953-7697 For,1NsPEcnoxS EXPIRES 1 AR FROM DATE ISSUED <br /> -_(��,�p� ----- --— -- <br /> JOADDRESS A�C _ CITY <br /> r. <br /> CROSS STREET - '�" ��••yy APN _, PARCEL SIE t C <br /> OWNER NAME f �t..-L.t PHONE F <br /> OWNER ADDRES �A <br /> /�J�n�'"`� `�� ,f�� ♦ CI7V!$TATE/ZIP - � �5 . <br /> CONTRACTOR '�- /TI L tC,"{,�^ I C iu 1 twc66-06 07 <br /> 1 �� } PHONE l�f <br /> CONTRACTOR ADDRES IIS/ Vv I CITY/STATE/ZIP' -'V '14J1 _I <br /> LICENSE C-42 �;!C-36 OTHER NUMBER �` EXPIRATION DATE r-� ^ r r ' ♦ t <br /> WATER TABLE DEPTH: 115 It GEOGRAPHICAL INFORMATION Coordinates X ► Y om- ` ` <br /> I I PERC TEST # � BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: LI NEW INSTALLATION RtPAIR/AUDITION I ENGINEER DESIGNED/ALTERNATIVE <br /> I I REPLACEMENT - _ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: :i RESIDENCE U COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPEIMFG Yb� ai�.1(.- CAPACITY 16 nO gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL It FOUNDATION It PROPERTY LINO ft <br /> .❑,! LIFT STATION SIZE TYPE OF PUMP 4 ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> yq LEACH LINES LEACHING CHAMBERS_ Z #OF LINES LENGTH OF LINES 40 It <br /> DISTANCE To NEAREST WELL IM4 It FOUNDATION It PROPERTY LINE 110 It ccc+++ <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH <br /> It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION_ I( PROPERTY LINE It <br /> VSUMPS WIDTH L NM�j�{ It DEPTH eft <br /> DISTANCE TO NEAREST WELL I FOUNDATION_ It PROPERTY LME ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH fl <br /> DISTANCE TO NEAREST WELL It FOU140ATIO14 R PROPERTY LINE 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 /> 24 H01 R 'C 1 REQUIRED FOR 1 TIONS-PLEASE CALL 209 953-7697 <br /> SIGNE 1 UY � .� TITLE DATE J_ <br /> 01), S!Lton CA�42132 <br /> 1 <br /> 1' <br /> �"P1u iii <br /> DEPARTMEN NLy <br /> Application Acce % 9 -I ?% Date — Area_E� Employee ID# <br /> Final Inspection t !,-fes Date _L / SP CAL PERMIT-Approved by 7TH <br /> Character of Soil t epth of 3 Ft: PiVS mp Soil Character: <br /> COMMENTS id Zjal j645 rL�$ 4`4 20. -f-ek - 'Y1Qw l0 I, � 1� <br /> PE SC RecBeived beck#! Amount _Uitte— — Permit/ - -- Invoice# Permit iD# <br /> Code INFO Remitted I Service Request# <br /> CIA <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 9!21110 <br />