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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE•S TOCK TON CA 95205-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL(2709)953-7697 FOR INSPECTIONS_ EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS=`!l `'{S CITY/21P_[_ —!C --- <br /> � I <br /> CROSS STREET :'I Y�c;= APN PARCEL SIZE !- t YtC <br /> OWNER NAME �' f=L.C�S j' <br /> J ,_��� PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITYISTATEIZIP <br /> I <br /> LICENSE i.L..C-42 .0-36 OTHER NUMBER- EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> J PERC TEST # �BUILDtNG PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION _...._.......--- <br /> x REPAIRIADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION _ <br /> INSTALLATION WILL SERVE; X\REsiDENCE COMMERCIAL G OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: "-z '' NUM8ER OF EMPLOYEES: <br /> IE, SEPTIC TANK TYPE/MFG E T t C-171', 2 <br /> CAPAL:11 Y I gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY 981 #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP _❑ PKG TX PLANT Q SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> L21- LEACH LINES LEACHING CHAMBERS #OF LINES -2- LENGTH OF LINESC� <br /> DISTANCE TO NEAREST WELL .SY -R- ft FOUNDATION_ ft PROPERTY LINE r{ ft <br /> C1FILTERBED WDTH ft LENGTH _ft/ DEPTH ft <br /> DISTANCE TO NEAREST WELL-- - ft FOUNDATION ft PROPERTY LINE R <br /> 0 MOUNDED WIDTH_ ft LENGTH fr DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY UNE It <br /> ❑ sumps WIDTH ft LENGTH ft DEPTH_ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION - ft PROPERTY LIN ^n ft <br /> ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH- S.A.. �� �ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROP'RTYC 'ti ft <br /> LJ SEEPAGE PITS NUMBER WIDTH ft DEPTHf LTt��jDAr- ft <br /> DISTANCE TO NEAREST WELL ft. FQSINOAT ION It PROPERTY LINE <br /> I HEREBY:CITIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILLBE GONE- ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> y Af1 l M Q-WOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL(209)953-7697 <br /> /\ SIGNED /.y�>,'� �' { TITLE_ DATE 1.5 1 <br /> t 1 i <br /> I- <br /> DEPARTMENT USE ONLY +J•"•'' <br /> Application Accepted B �` _- Date, "z- !-S:, Area % Employee ID#i}t St'�`f'r�cti�( <br /> r- <br /> Final Inspection By Data SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: ' PWSump Soft Character: _ <br /> COMMENTS Oc- ) f uT is F P--c i. ,) ( 4,T i--'-cc.c z)E-*J ,- I°�4>0 ��ter'- "L Le C-&,-07 1 r =,,v C JJ <br /> 'L1.4». vt� `.�Ct7E✓3 i74n+fL Tlc sitrVi- <br /> - - z <br /> _.. .Ek_+r..!_�i-z�..__.1_:?-_�!:'il_c <br /> PE SC Recetvad Check* Amount Permitt -— <br /> Data Invoice# Permit la# <br /> Code INFO B Remitted Service nest# <br /> _ -- --- <br /> 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4!24112 <br />