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ONSITE WASTEWATER TREATMENT SYSTEM PER UT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3" FL- STOCKTON CA 95202 - (209) 465-3420 <br />NON-REFUNDAB PE%1!A CALL(209) 53-7697 FOR INSPECTIONS E PIREppSt YEAR FRO 1 DATE ISSUED <br />JOBADDRESS Villar Cn-YCLIP <br />qj <br />CROSS STREET t APN_ '✓ / 3074=) /! PARCELSIZE C+ O� <br />OWNER NAME NE 66-0 ji��j �-A6 <br />�[7 �% // Jay+-•� PHONE <br />// Q <br />OWNER ADDRESS ¢rr�r_ r �. Trw f CITU/STATE/ZIP _ ` _� <br />CONTRACTOR �4(, I Ai�T, GlZ-}/ �V4 • �G... �sPHONE <br />,,2o�"-,g5/�'- <br />CONTRACTOR ADDRESS ADDRESS `�"�} A•�•� lrt�%�'7't-�- 7/_ /CITY/STATE/ZIP 7�OCH'CMJ CO 1(-5 <br />— <br />LICENSE ❑ C-42 ❑ C-36 OTHER 7 NUMBER M� EXPIRATION DATE. '� b <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X y <br />PERC TEST (S) NUMBER 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 />NUMBEROF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: _ <br />❑ SEPTIC TANK TYPE/MFG CAPACm 1 <br />❑ GREASETRAP <br />TYPE/MFG <br />ga # OFCOMPARTMENTS <br />CAPACITY gal #OF COMPARTMENTS <br />❑ PKC TX PLANT <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ SAND OIL SEPARATOR (ENCLOSED SYsrEM) <br />❑ LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES <br />(j <br />Y%iNIZ�` I <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />fl <br />❑ FILTER BED <br />WIDTH A LENGTH <br />ft DEPTH <br />ft <br />DISTANC£TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />b10L'NDED <br />WIDTH ft LENGTH <br />$ DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION D PROPERTY LINE <br />R <br />❑ SUMPS <br />WIDTH it LENGTH <br />R DEPTH <br />ft <br />DISTANCETONEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS <br />WIDTH ft LENGTH <br />It DEPTH <br />ft <br />DISTANCETO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />fl <br />❑ SEEPAGE PITS <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />1 HEREBY CE T,1FY THAT 1 HAVA PREPA THIS AP LICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STAT LYS AND RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY. <br />fly 24 HO ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 <br />SIGNED iTA/I <br />7' <br />TITLE 1'r+"'e '��P� I& <br />'.. <br />DATE 7 e <br />Y- <br />'i <br />_ <br />FFe+ <br />m <br />s <br />0 <br />N <br />DEPARTMEN EO• Ll' ��//)� <br />Application Accepted By Date Area Employee ID# 7 <br />Final Inspection By Date _ ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: PitISump Soil Character: <br />COMMENTS`j <br />V_�yL4/VLQWJ <br />d <br />PF, SC Received AmDunI Permit/ <br />Code INFO $ • Cash Remitted ate Service Request # invoice # Permit 1D# <br />62.01 -DDI <br />122/fl2 ONSITE WASTEWATER PERMIT <br />'y`4l w.l.cr. <br />/tae�l. <br />Y%iNIZ�` I <br />APRJ <br />el <br />DEPARTMEN EO• Ll' ��//)� <br />Application Accepted By Date Area Employee ID# 7 <br />Final Inspection By Date _ ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: PitISump Soil Character: <br />COMMENTS`j <br />V_�yL4/VLQWJ <br />d <br />PF, SC Received AmDunI Permit/ <br />Code INFO $ • Cash Remitted ate Service Request # invoice # Permit 1D# <br />62.01 -DDI <br />122/fl2 ONSITE WASTEWATER PERMIT <br />