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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. HAZELTON AVENUE-STOCKTON CA 95205 -(209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 <br />- <br />53-7697FOR SPECTIONSEXPIRES <br />1 YEAR FROM DATE ISSUED <br />JOB ADDRESS r <br />GTY'!!!P <br />l! rc.�,,� •^ q S"z0 6 <br />n NEW INSTALLATION I I <br />O �t I— '�T <br />(/ <br />71 <br />�I? <br />CROSS STREET <br />- <br />— APN _ _ <br />PARCEL SIZE <br />OWNER NAME rip Lv _ , <br />L <br />PHONE <br />OWNER ADDRESS 10 I _._,�, �._._ <br />CITYISTATE/ZIP <br />CONTRACTOR <br />NUMBER OF EMPLOYEES: <br />,B <br />CONTRACTOR ADDRESS du14-(..Cil <br />CITYISTATE/ZIP <br />_ <br />LICENSE DOC -42 OfIC-36 OTHER ,4 NUMBER _ _..—_E%PIRATION DATE <br />-- <br />WATER TABLE DEPTH: <br />It GEOGRAPHICAL INFORMATION: COOrdlnaleS X__ <br />Y <br />❑ <br />PERC TEST 8 <br />._ BUILDING PERMIT <br />_ LAND USE APPLICATION N <br />TYPE OF WORK: <br />n NEW INSTALLATION I I <br />REPAIR/ADDrT1ON <br />E <br />I ENGINEER DES GNED /A}T-RNl�ive <br />11 REPLACEMENT yf <br />OU *OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION lJ4L��''.i7'PV <br />INSTALLATION WILL SERVE: RESIDENCE <br />I1 COMMERCIAL <br />-1 OTHER---- <br />THER_NUMBER <br />NUMBEROF LIVING UNITS--. NUMBER OF BEDROOMS:--- <br />NUMBER OF EMPLOYEES: <br />,B <br />SEPTIC TANK <br />TYPE/MFG - _ <br />CAPACITY _ <br />gal n Or COMPARTIACNTS _ <br />1� <br />GREASE TRAP <br />TYPE/MFG ___ _ _._- _ _ _ _ - <br />_._._ CAPACITY _ _ <br />gal a of COMPARTLIENTS <br />(( <br />DISTANCE TO NEAREST: WELL <br />_ Il FOUNDATION _ _ _ <br />R PROPERTY LINE ___ II <br />O <br />LIFT STATION <br />SIZE __ TYPE OF PUMP_,_ <br />O PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />[I LEACHING CHAMBERS_ _ <br />it or LINES <br />LENGTH OF LINES _ It <br />DISTANCE TO NEAREST WELL —. __ <br />if FouNDATION <br />It PROPERTY LINE It <br />❑ <br />FILTER BED <br />WIDTH _ - . _ __ _ _ It LENGTH <br />_ ___It <br />DEPTH _ it <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION __It <br />PROPERTY LINE it <br />❑ <br />MOUNDED <br />WIDTH _ .. It LENGTH ____ <br />It <br />DEPTH _ It <br />DISTANCE TO NEAREST WELL- - <br />It FOUNDATION <br />_11 PROPERTYLINE__ __.._ it <br />❑ <br />SUMPS <br />WIDTH _ _. It LENGTH <br />___ . __ _ it <br />DEPTH 11 <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION <br />__11 PROPERTY UNE_ <br />❑ <br />DISPOSAL PONDS WIDTH __ _ 11 LENGTH _ <br />___ It <br />DEPTH It <br />DISTANCE TO NEAREST WELL <br />R FOUNDATION_ ___.._ <br />11 PROPERTY UNEIt <br />❑ <br />SEEPAGE PITS <br />NU/MBEq WIDTH_._— <br />__ __H <br />DEPTH it <br />DISTANCE TO NEAREST WELL <br />II FOUNDATION <br />R PROPERTY UNE it <br />1 f IEREBY CERTIFY THAT I HAVE i AHED IIIS APPLICATION AND THE YORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />/ TE LAWS AND RULES AND REGULATIONS <br />OF SAN JOAQUIN COUNTY. <br />Uti ttVJt'CL+1 tL/IVJ - f-LEM,= l M&r lcv <br />TITLE XAU­�.--- _- _ DATE <br />�DEPARTh1F.NT USE �0N LY y OI <br />Application Accepted By 10- .;._ _ Date_ 7j� Area Employee lDit <br />Final Inspection By _. Date, _ 17 SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 FI: PIVSump Soil Character:L_-_— <br />COMMENTS �.wciltrµt iaV1w ib eehl <br />' . L ZL11 {. `` SY//uL'I� W� 1.1A.0.1,:1'�tL 1L�A77147TM 'SY`r 19 4W low ro=c ru✓l`�v i cc__ <br />• ..IL Ln LC.FUI1 4l itL i'u • r•JAd- I�lt Lail - (�itd-ua rl 41..9f TG/' <br />hoc Amount Date Permlll Invoice M Permit IDS <br />Cosh flemiHad ServlcD Request Y <br />-T/ ,n V 1 1,4)c SjPnn/.Ia4BLL <br />ONSITE WASTEWATER TRTM14T SYSTEM PERMIT <br />