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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 GALL ZUY 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUEI <br />JOBADDRESS 3/000 SBllT/-/ Gfl2is/nl <br />CITYIZIP I7" , 0C= �- �G9SAKa�3 <br />7G <br />CROSS STREET OunKFiK FiR Y Rom 11% PARCELSIZEE <br />"I <br />¢SyQA <br />OWNER NAME YNRT✓I N�PHONE ;o - -X <br />OWNER ADDRESS 3IOOO /. e1 1:C&AA1CITY/STATE/ZIP cV pOW <br />CONTRACTOR jQYESET�'DN/SI_rfAl�, PHONE "?ef <br />CONTRACTOR ADDRESS a' 0.z <br />� CITY/STATE/ZIP /K RCsk j A 'e <br />_ <br />LICENSE 011C -42[10C -36C-36 OTHER /C • `/i ` E • NUMBER, EXPIRATION DATE <br />WATER TABLE DEPTH: /D O f ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION LJ REPAIR/ADDITION ❑ 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 />❑ SEPTIC TANK TYPE/MFG CAPACITY <br />❑ GREASE TRAP TYPE/MFG CAPACITY <br />DISTANCE TO NEAREST: WELL ft FOUNDATION _ <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />❑ LEACH LINES <br />❑ LEACHING CHAMBERS <br />Amount <br />Remitted <br />Date <br /># OF LINES <br />Invoice # <br />DISTANCE TO NEAREST <br />WELL <br />3 7 <br />ft <br />FOUNDATION <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />il <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LENGTH OF LINES ft <br />ft PROPERTY LINE ft <br />ft DEPTH ft <br />ft PROPERTY LINE ft <br />ft DEPTH ft <br />ft PROPERTY LINE ft <br />ft DEPTH ft <br />ft - PROPERTY LINE ft <br />ft DEPTH ft <br />ft PROPERTY LINE ft <br />_ft DEPTH ft <br />ft PROPERTY LINE ft <br />I HEREBY CERTIFY TFjj I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />�J! STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />IVIIIVIIY IYI gg r7u%g4dw V1i1Vl.0 IVV, m'c rCC VIr%CV rVIR IIVJrC6. 1 IVIV.7 - rLCriJC VP11_L LL/, <br />SIGNED TITLE OjWAI� DATE <br />Application Accepted By <br />Final Inspection By, <br />Character of Soil to Depthf 3 <br />COMMENTS rrio <br />1*rs'P."_ ,Cs <br />DEPARTMENT USEONLY <br />Date 2 Area 4 Employee ID# <br />Date i ❑ SPECIAL PERMIT -Approved by <br />Pit/Sumo Soil Character: <br />PE <br />Code <br />SC Received Che <br />INFO B <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />3 7 <br />t `9y" <br />2.141 1 is, <br />S''O bJ=� <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />a <br />0 <br />