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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEM 1686 E. RAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />/J CALL 209 53-7697FOR SAEC77ONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS / y CnY/ZIP O-147 ?-vt ^ Cis ZO b <br />CROSS STREET <br />j��- APN1 %f - O L{ I- u' PARCEL SIZE 'dam <br />��"y' <br />OWNER NAME / / r/K't..i� ._ ._ PHONE <br />OWNER ADDRESS 16 I L ;a � I -- _ Crry/STATEMPP� - A 9yL�9 <br />CONTRACTOR R?s-u�r tyi __ PHONE 516 <br />D/-, !!�I% 2 7b y y <br />CONTRACTOR ADDRESS &x6(1 14 -L)7 _ CrrY/STATEfZIP <br />LICENSE ❑OC -42 ❑nC-38 OTHER �.[t1y!!%I NUMBER_ _ _ EXPIRATION DATE <br />WATER TABLE DEPTH: <br />It GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />Fl PERC TEST # <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />Fi NEW INSTALLATION I <br />REPAIn/ADDITION <br />Il ENGINEERDESIGNED1 TERN E <br />it PROPERTY LINE it <br />I 1 REPLACEMENT yf <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />pr DESTRUCTION <br />INSTALLATION WILL SERVE: jc� RESIDENCE <br />I I COMMERCIAL <br />OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />DISTANCE TO NEAREST <br />NUMBER OF EMPLOYEES: <br />.3 SEPTIC TANK <br />TYPE/MFG _ _ <br />CAPACITY <br />__ gal # OF COMPARTMENTS <br />GREASETRAP <br />TYPE/MFG __. -_ <br />..._ CAPACITY _ <br />gal # OF COMPARTMENTS <br />(( <br />DISTANCE TO NEAREST: WELL _ _ _ <br />it FOUNDATION <br />It PROPERTY LINE it <br />❑ LIFTSTATION <br />SIZE TYPE OF PUMP__.____.._0 <br />PKGTXPLANT 0 <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINTS <br />Li LEACHING CHAMBERS _ <br />_. _ <br /># OF LINES <br />_ LENGTH OF LINES it <br />DISTANCE TO NEAREST <br />WELL <br />it FOUNDATION <br />it PROPERTY LINE it <br />❑ FILTER BED <br />WIDTH <br />it <br />LENGTH <br />it DEPTH it <br />DISTANCE TO NEAREST <br />WELL <br />it FOUNDATION <br />it PROPERTY LINE it <br />❑ MOUNDED <br />WIDTH <br />it <br />LENGTH <br />it DEPTH it <br />DISTANCE TO NEAREST <br />WELL <br />____ <br />it FOUNDATION <br />it PROPERTY LINE it <br />❑ SUMPS <br />WIDTH <br />it <br />LENGTH <br />it DEPTH it <br />DISTANCE TO NEAREST <br />WELL <br />it FOUNDATION <br />it PROPERTY UNE it <br />❑ DISPOSAL PONDS WIDTH <br />it <br />LENGTH <br />it DEPTH it <br />DISTANCE TO NEAREST <br />ELLit <br />WELL--- <br />FOUNDATION <br />it PROPERTY UNE it <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH _ <br />_ _ <br />__8 DEPTH Ii <br />DISTANCE TO NEAREST <br />WELL <br />11 FOUNDATION <br />it PROPERTY LINE it <br />I HEREBY CERTIFY THAT 1 HAVE PS <br />AREDHIS APPLICATION AND THE WORK WILL RE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />I HEREBY CERTIFY THATI HAVS ATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />'OR INSPECTIONS - PLEASE CALL (20: <br />TITLE A O _.._ DATE <br />ME T t SE,©� <br />Application Accepted By /dl /y� _ Date_70,11 Area O0 Employee ID# <br />Final Inspection By -_. Date LI SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS 1 1 <br />41, / . ./el J. a`ZtIIL - S� k u,1 L w 4Y 15 LLR low' Cly X42 uw <br />SC Received hec Amount Date termly Invoice # Permit ID# <br />INFO I Cash Remitted Service Rtguest # <br />opsI 110 I 71%)os — SR 9 <br />ONSITE WASTEWATER <br />0 <br />.VPAIL,ED <br />PERMIT It I t <br />