Laserfiche WebLink
ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-MEFUNDABLE F E MIT / (:ALLlUJ '.ib:i-/()5/ FOR INSPECTIONS LXPIRES 7 YEAR FROM DATE ISSUEI <br />JOB ADDRESS I. ���� I r/i`C /�,cJ /� / V C�ITY/ZIP Lin.LrI e --A <br />CROSS STREET _� I V I APN 6/ ) �& J PARCEL SIZE f� <br />OWNER NAME 'C 04/ A4C Sib ,S PHONE(2") <br />OWNERADDRESS P G flex le©? CITY/STATE/ZIP LindC44 Cil` QS13 C <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS <br />LICENSE ❑ C-42 ❑ C-36 OTHER <br />CITY/STATE/ZIP <br />NUMBER EXPIRATION DATE <br />PE <br />Code <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />CCh #/ Amount <br />ash Remitted <br />Permit/ <br />Date <br />Request # <br />❑ PERC TEST # <br />BUILDING PERMIT # LAND USE APPLICATION # <br />ZdaL <br />TYPE OF WORK: 15( <br />NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />(Service <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />IF <br />TYPE/MFG CAPACITY gal # OF COMPARTMENTS r/ <br />❑ GREASE TRAP <br />TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />1 <br />OO l'"1 �r'� <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />(I LEACHING CHAMBERS # OF LINES LENGTH OF LINES <br />ft <br />f r1 <br />DISTANCE TO NEAREST WELL �r � ft FOUNDATION 4 ft PROPERTY LINE 7 7 <br />ft <br />❑ FILTER BED <br />WIDTH ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ MOUNDED <br />WIDTH ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS <br />WIDTH ft LENGTH ft DEPTH <br />ft <br />SEEPAGE PITS <br />E�AREST WELL ft FOUNDATION ft PROPERTY LINE <br />DISTANCE TO N/� <br />NUMBER !(/ WIDTH &2 // ft DEPTH �iS/ <br />ft <br />ft <br />DISTANCE TO NEAREST WELL I 5d f ft FOUNDATION f ft PROPERTY LINE S/f <br />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 />MINIMUM 24 <br />HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED ✓ TITLE DATE <br />S <br />�y <br />1� <br />'I <br />E P A R T M E T U E O LY <br />Application Accepted BV <br />Date Area Employee lD#�� <br />Final Inspection By <br />Date ❑ SPEC AL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: sol <br />COMMENTS <br />r <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />CCh #/ Amount <br />ash Remitted <br />Permit/ <br />Date <br />Request # <br />Invoice # <br />Permit ID# <br />ZdaL <br />(Service <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />r <br />