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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE <br /> PERMIT _ CALL(209)953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS��_!� �(�-- CITY/ZIP f Vii(/) <br /> CROSS STRCL-Yt-G/7 �� APN Z <br /> EET -.C �- -� 3� C1 PARCEL SIZE <br /> OWNER NAME <br /> / .0 IG� / GCi�C. ` PHONEL- �VVQ i <br /> OWNER ADDRESS /� O b r:,y}L� ��4o le CITYISTATEMP <br /> CONTRACTOR 0/)/C,Ale- ��j1, J'L Y ✓1 �-"�C^ PHONE <br /> CONTRACTOR ADDRESS!!_l7 UT'V �'v/J✓'L`fl I ^ � C11YISTATEiZIP <br /> LICENSE i 1 C-42 i.)-C-36 OTHER NUMBER //r(7JrE%PIRATION DATE�f J J <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> U PERC TEST a [BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION 4 REPAIR/ADDITION ENGINEER DESIGNED iALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE I J COMMERCIAL OTHER <br /> NUMBER OF UV:NG UNITS:_ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK Tti PElMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE To NEAREST: WELL It FOUNDATION ft PROPERTY LINE _ ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 0l LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF UNFS s ft <br /> •!\ DISTANCE To NEAREST WELL R FOUNDATION �ft PROPERTY LINE. 1 I R <br /> WIDTH ft LENGTH ft DEPTH '---7—' ft <br /> DISTANCE TO NEAREST WELL I FOUN ATION '— ft PROPERTY LINE. <br /> ❑ MOUNDED W!DTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WDTH R LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE —,It <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST JkELL ft FCUNDATION R PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH —it DEPTH R <br /> DISTANCE TO NEAREST WELL It FOUNDATION R PROPERTY LINE It <br /> 1 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 /> T -P -7 <br /> 62 <br /> SIGNED TITLE C/�It _ _ DATE <br /> I I <br /> I - <br /> I <br /> NT <br /> Lf <br /> � ED <br /> 019 <br /> UNTY <br /> AL <br /> D TENT <br /> I I ±H##_ <br /> AprMENT SE ONLY <br /> Application Accepted By ` I �� Date - - Area Employee 10# <br /> Final Inspection By Date SPECIAL PERMIT-Approved Dy <br /> Character of Soil to Depth 3 Ft: ' PltlSump Soil Character:_ <br /> COMMENTS O q <br /> PESC Received Ct1ec Amount Permits <br /> Date Invoice# Permit ID# <br /> Code <br /> INFO y8 emitted Service Re uest# <br /> 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4114;;8 <br />