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<br /> C"�? ;�. 4 ONSITE WASTEWATER TREATMENT SYSTEM PERMIT
<br /> SANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 E.HAZEL70N AVENUE-STOCKTON CA 95205-(209)468-3420
<br /> ��.�����CA U9 953�7697fFOR INS C77ON E ES 1 Y A FRO ATE ISSUED
<br /> JOB ADDRESS _.rJ�sr__UJI_RIIFL_� , ./- 7Y/ZIP y� , _....
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<br /> CROSS STREET __. ......_ ..!..�:LV!�..-_ APNO.j.= _ ./4 'Q.,,�`,,........_...._..PARCCEE-L-(*SIIZ�Ey�_--r� ILJ�
<br /> OWNER NAM _
<br /> OWNER ADDRESS _55. 9t._._._V. ....___ _,.•,,, CMISTATER LOD&60-
<br /> CONTRACTOR
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<br /> ' .__ A'l6!-_�-�,._`A'_1J1J *..._.� 7�W�QV PHONE....... ". .._. __lZ.__
<br /> CONTRACTOR ADDRESS �0Q ,__-A._,_�!�,,,�/ _„_, }e_, „�V.._...._WW-,.W! —CITYISTATE/ZIP.��,
<br /> LICENSE )C-42 0i::'C-36 OTHER_ ,____-_„_„_,,,,,-, NUMBERt 05__1] ._EXPIRATIONDATE_,,,,,.._.._........._.
<br /> WATER TABLE DEPTH: .,..,.._,_„ft GEOGRAPHICAL INFORMATION: Coordinates X _.
<br /> PERC TEST #_..._.----....._.-.._-- BUILDING PERMIT#__..._.._._..._...,_..__.—_.__.LAND USE APPLICATION
<br /> TYPE OF WORK: ._, NEW INSTALLATION REPAIR/AoorrtoN ENGINEER DESIGNED(ALTERNATIVE
<br /> REPLACEMENT -...,,,.- 1; OUT•OF-SERVICE SEPTIC SYSTEM DESTRUCTION
<br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER.__....._____..........
<br /> _._._____...-..___..__.
<br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:._. -A' �___�_....... NUMBER OF EMPLOYEES:,...._._—__--�
<br /> SEPTIC TANK TYPE/MFG T�� -_...__, CAPACITY _f K-►.L� - gal #OF COMPARTMENTS...
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<br /> DISTANCE TO NEAREST: WELL -��-�.�� h Ft`7JNDAt1<5N r�. SAI #OFCOMPARTMF.NTS,„,-,,,_,_,-___._...
<br /> L.; GREASE TRAP TYPE(MFG ± CAPACITY_.__......_._.._ .-y it PROPERTY LINE _._S -t ►t
<br /> ❑ LIFT STATION SIZE.. TYPE OF PUMP_,--..,.❑ PKG TX PLANT 0 SAND OIL SEPARATOR(ENCLOSED SYSTEM)
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<br /> LEACH LINES Y LEACHINGCHAMBERS_ n
<br /> LENGTH OF LINES
<br /> .._................-._.._ #OF LINES_16-, ,_-�0-C ._._ _—ft
<br /> DISTANCE TO NEAREST WELL._._Moa+'
<br /> ft FOUNDATION_,,,,,_. It PROPERTY LINEIt
<br /> ❑ FILTER BED WIorR ._..................................._._. ft DEPTHft
<br /> .... it LE _...._..__........ ...... ..
<br /> DISTANCE TO NEAREST WELLit FOUNDATION it PROPERTY LINE ...it
<br /> ❑ MOUNDED WIDTH -_---it LENGTH_ _.... .._...... - _it DEPTH......____ ft
<br /> DISTANCE TO NEAREST WELL................._._....__.ft FOUNDATION -._;:.,:W..,,........4, PROPERTY UNE It.
<br /> ❑ SUMPS WIDTH..._.................._._......__.........._It LENGTH__. .__.._,.,,_........ it DEPTH -- __- _If
<br /> DISTANCE TO NEAREST WELL.,....,.._.__: If FOUNDAMON._....._..._..._.._...__..,....__...it PROPERTY it
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<br /> ❑ DISPOSAL PONDS WIDTH it LENGTH._ _ St DEPTH _It
<br /> DISTANCE TO NEAREST WELL it FOUNDATIONIf PROPERTY LINE-.,.,,T it
<br /> ❑ SEEPAGE PITS NUMBERWIDTH_--.._...__...__.._._..�_.-- II DEPTHIII
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<br /> DISTANCE TO NEAREST WELL__.._.._—_.._...._.._ N FOUNDATION It PROPERTY LINE
<br /> I t EREBY 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.
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<br /> MI ! HOU A L UIREO FOR IN F t9r S-P QSE CALL 2O9 953-7697
<br /> SIGNED TITLE._-..,. _.._—..�......� J DATE _..._
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<br /> Application Accepted By -- Date /.. L, Area �R9 Employee ID# c 7
<br /> Final Inspection By-- _. Oate,c �, ,L� _ l SPECIAL PERMIT-Approved by
<br /> Character of Soil to 0 It o 3 tPit/Surnp Soil Character: .________............_-__--_.._...._
<br /> COMMENTS 4ur. .15-
<br /> PE
<br /> 5 PE SC Received hoc Amount PermiU
<br /> Code INw B as Remitted D°t° _ Service Request# Invoice# Permit ID#
<br /> 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT
<br /> 4124112
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