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Pf <br />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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS / CITY/ZIP L - <br />CROSS STREET / l' APN 6�I) J I PARCEL SIZE <br />OWNER NAME 4 Tj� I/L'i (� L L�F�, I or --b 1 r-- PHONE <br />OWNER ADDRESS C:' r -)OT O> r -CITY/STATE/ZIP & )5'ba fu CA <br />ilCONTRACTOR ! PHONE <br />% <br />47 <br />CONTRACTOR ADDRESS ��_�l �fiVV' �L- -6" CITY/STATE/ZIP <br />LICENSE C-42 L -IC -36 OTHER ►�i NUMBERv (/ PIRATION DATE Z9 <br />WATER TABLE DEPTH:"' ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I i ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM LJ DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: /loe_ NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />i iJ �irx <br />CAPACITY <br />CAPACITY <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />i LEACH LINES <br />❑ FILTER BED <br />❑ MOUNDED <br />❑ SUMPS <br />❑ LEACHING CHAMBERS # OF LINES <br />DISTANCE TO NEAREST WELL ft FOUNDATION_ <br />WIDTH ft LENGTH <br />DISTANCE TO NEAREST <br />WIDTH <br />DISTANCE TO NEAREST <br />WIDTH <br />DISTANCE TO NEAREST <br />WELL ft <br />ft LENGTH <br />WELL ft <br />ft LENGTH <br />WELL ft <br />FOUNDATION <br />FOUNDATION <br />FOUNDATION <br />[o'" LENGTH OF LINES 7" / ft <br />ft PROPERTY LINE 7 ft <br />ft DEPTH ft <br />ft PROPERTY LINE yft <br />ft DEPTH "T <br />r I rt <br />ft PROPERTY LINE %Vlcnft <br />ft DEPTH ' ft <br />ft PROPERTY LINE u ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH SANJOA ft <br />DISTANCE TO NEAREST WELL fttFOUNDATION ft PROPERTY LIN IRONM N7Yft <br />SEEPAGE PITS NUMBER_ WIDTH n ft DEPTH ZS PARTIViEAtr ft <br />✓" DISTANCE TO NEAREST WELL l ft FOUNDATION // ft PROPERTY LINE 5� 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 />Iv111Vll Iv1C't r7VLI --M IJV VL.0 1VL/►IL'c rSCLdIlIrtCLI ruri 11VJrCL,ilulvJ-rLCHJC L.HLL cvy yzj'o-/uvf <br />SIGNED TITLE ` DATE <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to De <br />th of <br />COMMENTS lie r <br />Date `I/� -1;1- • Area Employee ID# <br />Z <br />Date I z A ❑ SPECIAL PERMIT -Approved by <br />PittSump Soil Character: <br />G 1^ <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Chec <br />ash <br />AmountPermit/ <br />Remitted <br />D It <br />Service Request # <br />Invoice # <br />Permit ID# <br />zit; <br />n► <br />3 <br />i <br />bbl 3 3 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />