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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 PERMIT `CA)LL 2409 953-769`7 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS L b0 �- { t,_o,Pc- GylVC't GS C� CITY/ZIP <br /> CROSS STREET °�a-I�$-�.t/ GsY,✓�- APN t-3 23Q2�j' PARCEL SIZE Z'C- 1 Y <br /> 0 <br /> p / <br /> WNER NAME e L� PHJ,ON,E,I� 6 -//6c) <br /> OWNER ADDRESS —CITY/STA7E/ZIP <br /> CONTRACTOR, A.. PHONE <br /> v//�� ` �/A . �]a� � <br /> CONTRACTOR ADDRESS !/l�y��VLJI(/Ll6H%!7� �J���.��y/�� CITY/STATE/ZIP <br /> LICENSE OC-42 EIC-36 OTHEflFlR NUMBER?& i-l`1—EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM X DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ GREASETRAP TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> DISTANCETO NEAREST: WELL It FOUNDATION it PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OFLINES LENGTH OFLINES It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO.NEAREST WELL ft FOUNDATION It PROPERTY LINE It <br /> ❑ MOUNDED WIDTH It LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH It LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH It LENGTH It DEPTH It <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTYLINE 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 /> fflN <br /> 1MUM 2 VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE'CALL 209 953-7697 <br /> SIG TIT[^' DATE <br /> trn <br /> v <br /> DEPARTMENT US ONLY <br /> Application Accepted By` Date _� Area 0 ft Employee ID# 0'7 <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> "Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS AA.)0 S.c 4,y sit,.-✓ C',t l—cL 2 TD (�c S E ram t�1a s c 12c.%vL <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash RemittedService Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />