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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS I �ClL<� '�f.' CITY/ZIP SMCl/ �-chi <br />CROSS STREET //- ("I r, 00. �c( <br />OWNER NAME C L/f�G'Cf�C <br />PHONE <br />PARCEL SIZE <br />OWNER ADDRESS Lel <br />cz7 91TY/STATE/ZIP <br />CONTRACTOR L / 'PHONE } <br />s7 <br />CONTRACTOR ADDRESS CITY/STATE/ZIP /n /" <br />LICENSE ❑ k-42 [10C-36 OTHER NUMBER`W/V Z(I <br />� <br />EXPIRATION DATE <br />WATER TABLE DEPTH: <br />❑ PERC TEST # <br />TYPE OF WORK: <br />ISANCE -1— <br />vim+ ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />BUILDING PERMIT # LAND USE APPLICATION # <br />IJ NEW INSTALLATION REPAIR/ADDITION Li ENGINEER DrA/SSII�"�'1 <br />❑ REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTIO <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL <br />❑ OTHER MFNr <br />Permit ID# <br />o <br />3 <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG G ' / CAPACITY leYOo <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 80 ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />X! <br />LEACH LINES <br />❑ LEACHING CHAMBERS # of LINES l <br />LENGTH OF LINES T� ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTI4 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 WIDTH ft LENGTH ft <br />DEPTH ft <br />D NW ft FOUNDATION <br />ft PROPERTY LINE ft <br />TTO ELL <br />SEEPAGE PITS NUMBER 01/ WIDTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION 5 G ft PROPERTY LINE 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 C, <br />SIGNED TITLE li�oi�S��'` DATE <br />III �j 111 11111 1 11 1.11 r0'jj",p�,jj&1H4-jjjjjjj III <br />tD P A RTMEN71USll OtZLY <br />Application Accepted By Date Area Employee ID# <br />Final Inspection By Date zd ❑ SPE IAL PERM T -Approved by <br />Character of Soil to Depth of 3 Ft: P't/Sump Soil Character: <br />COMMENTS <br />PE <br />Code <br />SC Received Check <br />INFO B s <br />Amount Date Permit/ <br />Remitted Service Request # <br />Invoice # <br />Permit ID# <br />o <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />r <br />