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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET - STOCKTON CA 9$202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS <br />2.SQ <br />-7r-� <br />! ✓ CITY/ZIP / <br />/0 <br />CROSS STREET <br />tr <br />6 LE -,J- t� <br />�/' APN Z 6-3-- �O O I� <br />PARCEL SIZE 10. 19 <br />OWNER NAME <br />G r a n I Tt� <br />[, on dPyd i ryY ,— C.Q_ PHONE <br />Q p�r 1/ <br />209 /O 2 - L Zr0 <br />OWNER ADDRESS <br />❑ <br />CITY/STATEIZIP <br />WIDTH <br />CONTRACTOR <br />r• <br />U R r Gr l� r^I/. ' HONE <br />J 3 9 <br />/-s <br />CONTRACTOR ADDRESS _ r• O <br />`// <br />Oil Z 6 3 CITY/STATE/ZIP <br />LICENSE QC -42 <br />QC -36 OTHER 0641 14 NUMBER I EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />C PERC TEST #BUILDING PERMIT # 00IS AND USE APPLICATION # <br />TYPE OF WORK: V, NEW INSTALLATION i I REPAIR/ADDITION I- ENGINEER DESIGNED /ALTERNATIVE <br />❑ REPLACEMENT Li DE <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL fl THER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: MBER OF EMPLOYEES: 30 <br />SEPTIC TANK TYPE/MFG/' �-�- ( / APACITY 2 0 <br />O GREASE TRAP TYPE/MFG. C <br />DISTANCE TO NEAREST: WELL 100 1- ft FOUNDATION_ <br />❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT <br />L� gal # OF COMPARTMENTS Z <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE tt <br />O SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />J, <br />LEACH LINES <br />LEACHING CHAMBERS <br />2.SQ <br />#OF LINES <br />/0 <br />LENGTH OF LINES_ /OO ft <br />Permit ID# <br />DISTANCE TO NEAREST <br />WELL/ <br />00 <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE it <br />❑ <br />SUMPS <br />WIDTH <br />—ft <br />LENGTH <br />ft <br />DEPTH it <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />O <br />DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />R PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE It <br />1 HEREBY CERTIFY THAT 1 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 />MINIMUM R ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED [% �cC�� , TITLE _C.�r — ok/),� DATE <br />N <br />it <br />Application Accepted B e S' rea E loyee ID# Scr -4 gG <br />Final Inspection By Date ❑ SPECIAL PERMIT -Approved by 7 <br />Character of Soil to Depth of'3 Ft: 01 Itlgump Soil Character: <br />COMMENTS .n14Ew t-oF S s A-f,.,J .--{ ce <br />3 D <br />PE <br />S <br />INFO <br />Recelve <br />B <br />Check <br />-ash/ <br />Amount <br />emitted <br />Date It/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />/r`2 -{Code <br />fg <br />/� <br />'Z -SV <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />10/4107 <br />