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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 <br />SEPTIC TANK <br />209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUE[ <br />JOB ADDRESS 2Z 7 t <br />/CALL <br />G57 -Are- <br />CITY/ZIP CITY/ZIPOC <br />tQ <br />CROSS STREET 140WA'1 po <br />APNQI2-O [ZIO , 7i/ <br />PARCEL SIZE <br />OWNER NAME t 1)0.<0 IL•ZCAL <br />S`O ✓1 <br />LIFT STATION <br />PHONE WI -410 ^,$ SZ -t <br />OWNER ADDRESS <br />�i <br />—CITYISTATEIZIP <br />LENGTH OF LINES ft <br />CONTRACTOR C Gv.U, c <br />"'L PIV WIASI <br />g PHONE ZQ R <br />^ Ll G t <br />CONTRACTOR ADDRESS Po <br />acks 1 23 ( <br />CITY/STATE/ZIP <br />DEPTH 4 i" ft <br />LICENSE 110C-42 VUC-36 <br />OTHER 64k*4 <br />NUMBER1R3%4i4 EXPIRATION DATE <br />(O^ZC - LO <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: LJ NEW INSTALLATION L REPAIRIADDITION L ENGINEER DESIGNED /ALTERNATIVE <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 />❑ <br />SEPTIC TANK <br />TYPE/MFG CAPACITY <br />gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP <br />TYPE/MFG CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />SR <br />LEACH LINES <br />❑ LEACHING CHAMBERS # OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />7� <br />FILTER BED <br />WIDTH LL ft LENGTH _ ft <br />DEPTH 4 i" ft <br />t <br />DISTANCE TO NEAREST WELLa1 FOUNDATION t fi <br />G <br />ft PROPERTY LINE / ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft -- PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER WIDTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE <br />WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED <br />��1�—� <br />TITLE �l� �Cr <br />DATE 2� � Y g <br />` PARTM <br />Application Accepted ByalfikFl. Date <br />Final Inspection By d Date <br />Character of Soil to Dep of 3 F <br />COMMENTS 71, eWijC <br />Area '��1 Employee ID# <br />❑ SPECIAL PERMIT -Approved by . <br />Soil Character: <br />T <br />X -o-te <br />'I t l <br />PE SC <br />Code INFO <br />Received Check#/ Amount <br />B Cash Remitted <br />Date Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />r� <br />6 �� <br />sR007 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />