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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 C� lO CITY21P__2 <br />CROSS STREET /�/ice % �t� APN v y 1 60 —410 <br />OWNER NAM <br />PARCEL SIZE IV ( <br />?z c-- e54 ;ri <br />OWNER ADDRESS X LUV CITY/STATE/ZIP <br />CONTRACTOR / C /� ��l�I�.�'�r�G PHONE <br />CONTRACTOR ADDRESS Z iT �� ���•� rL� _CITY/STATE/ZIP <br />LICENSE __&-42 FIC -36 OTHER / L' NUMBER-� EXPIRATION DATE <br />N1 ' <br />WATER TABLE DEPTH: I.1 J 1 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DE IGNED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM X` DESTRUCTION Te' !� K <br />INSTALLATION WILL SERVE: ❑ RESIDENCE X COMMERCIAL OTHER / <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />J� SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY Z600 ¢ /Legal # OF COMPARTMENTS___ <br />���JJ CAPACITY gal If OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL 9,FOUNDATION ft PROPERTY LINE ft <br />LIFT STATION SIZE .TYYPPEE OF PUMP L3PKG TX PLANT LI SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />X` AT--rA-l�w _._...... _ ____....._ .._._.__.__. _.. <br />❑ <br />LEACH LINES <br />CI LEACHING CHAMBERS <br />hec <br /># OF LINES <br />D to <br />Permit/ Invoice # <br />Permit ID# <br />DISTANCE TO NEAREST WELL <br />INFO <br />ftOUNDATION <br />ash <br />f <br />FILTER BED <br />WIDTH ft <br />LENGTH <br />` <br />ft <br />v <br />DISTANCE TO NEAREST WEL <br />�UNDATION <br />❑ <br />MOUNDED <br />WIDTH It <br />LENGTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />❑ <br />SUMPS <br />WIDTH ft <br />LENGTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />❑ <br />DISPOSAL PONDS WIDTH _ ft <br />LENGTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUND. -,TION <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION <br />LENGTH OF LINES ft <br />ft PROPERTY LINE ft <br />DEPTH 7 „ ft <br />ft PROPERTY LINE ft <br />DEPTH ft <br />ft PROPERTY LINE ft <br />DEPTH P®Y&L,, .__ft <br />wac. Mr <br />ft PROPERTY LINE ft <br />DEPTH t <br />ft PROPERTY LINE——� ft <br />ft <br />ft DEPTH 20 ft <br />ft PROPERTY LINE � OAQU ft <br />n.. <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIIaRr��T <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINI 24 HOUR ADVAY6E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED, TITLE �� d DATE <br />Application Accepted B \ <br />Final Inspection By <br />Character of Soil to DeptW t:_ <br />COMMENTS <br />b` PARTMEN_T IJ SE O Y �A� <br />Date Area Employee ID#_ <br />Date_ I I ,� c� ❑ SPE AL PERMIT -Approved by <br />Pit/Sump Soil Character: <br />T <br />PE <br />SC <br />Received <br />hec <br />Amount <br />D to <br />Permit/ Invoice # <br />Permit ID# <br />Code <br />INFO <br />ash <br />Remitted <br />rvice Request # <br />S9,6k <br />V'r-i r'ek Cis heal- C' d_P�r' <br />42-01 eWNSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />Y <br />