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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953--7697 FOR INSPECTIONS EXPIRE <br /> S 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z 3k 11 5• JA-0K -r . CITy/ZIP Q I Ipe7j _l T? <br /> CROSS STREET W ES-- 2•t Po Vv APN 1--7 O -34 _PARCELSLZE z <br /> 0 <br /> OWNER NAME (Z-1 V e-t M L1/j�& PHONE <br /> OWNER ADDRESS 1 333 y-) • T 44-% CIN/STATE2P Imo1 PrK �c-Sp� yyS�3 Z <br /> (.eZ(•e <br /> CONTRACTOR UttEU �e- PHONE 3&q- c3-7Y-- <br /> CONTRACTOR <br /> 3-7r <br /> CONTRACTOR ADDRESS O-) U�� ST. CITY/STATE21P Lyb( LAc,T7-qz) <br /> y' <br /> LICENSE ❑C-42 QC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: COOrdinateS X Y <br /> PERC TEST # F BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY 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 SYSTEMA)) <br /> 8AYry��+ <br /> ❑ LEACH LINES El LEACHING CHAMBERS #OF LINES LENGTH OF LINES Ia7� �e• 1 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft el <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ��I f i <br /> ' <br /> DISTANCE To NEAREST WELL I ft FOUNDATION R PROPERTY LINE U 2020 <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH aft^ C <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE "1t'� IN C,OU Ty <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH HrzA •,.,, MENTAL <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE E ARTIb(ENT <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft 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 /> I UM 24 H/OO VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED _ / TITLE -�' ✓nU� DATEHit $-L-- <br /> J <br /> DEPARTMENT USE PNLY +.J <br /> Application Accepted By Date II 3, <br /> `c Area r CA Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PivSump Soil Character. <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service Re uest# <br /> �aaa S23 / . / .�`7 -I -?00 1 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />