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1:^ 5cci, Z -Z.- 1`7 177►^ f <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 ISSUE[ <br />J <br />JOB ADDRESS q �2 7 F }/D /?44 /" /4 Ll, . CITY/ZIPJ 6 C o A) 5'2 <br />CROSS STREET / L APN /S� i 'v PARCEL SIZE l <br />OWNER NAME 6EN PHONE <br />OWNER ADDRESS -'7,ya/lly�/� tl c» CITY/STATE/ZIIP <%bA.) C /4 . 95.1 S <br />CONTRACTOR PHONErAD9 ) q.2, —'? as 6 <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE ❑ C-42 ❑ C-36 OTHER NUMBER EXPIRATION DATE <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 ENGINEER DESIGNED /ALTERNAT E <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION/ <br />INSTALLATION WILL SERVE: ❑ RESIDENCE L] COMMERCIAL OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />CAPACITY <br />CAPACITY <br />ft FOUNDATION <br />❑ PKG TX PLANT <br />❑ LEACH LINES <br />I ! LEACHING CHAMBERS <br />Received Check#/ <br />By Cash <br />Amount <br />Remitted <br /># OF LINES <br />Permit/ <br />Service Request # <br />DISTANCE TO NEAREST <br />WELL <br />id-WIT47 <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 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 />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />ft <br />ft <br />ft <br />ft <br />LENGTH OF LINES _ <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH _ <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <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 />SIGNED t�-�� <br />t <br />Application Accepted <br />Final Inspection By_ <br />Character of Soil top <br />COMMENTS �� <br />DATM / / oZ. / / <br />TMENT US ONLY <br />Date Area Employee ID# <br />Date ❑ SPEC AL PERMIT - Approved by <br />PiUSumo Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Received Check#/ <br />By Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />id-WIT47 <br />;?--z <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />