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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTVF- 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECT70NS /� EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 3z t S EGGS ��J CfTY21P {-►tfM <br />CROSS STREET ^Ny r `- J I V A �) t APN Lt705 _ 31570 <br />�V ✓ 7PARCEL SIZE !/ <br />OWNER NAME , K y L LA Ar /-A (j , PHONE <br />OWNER ADDRESS Es i 7 (��yJ� $ 1 V n Ci - 1 CITY/STATE/ZIP A co" --p J q'�Zy <br />CONTRACTOR V4F—S 7 -j L PHONE -53c) -, 3 � y <br />CONTRACTOR ADDRESS tV� �r f I S "t CITY/STATE/ZIP Ly D -T <br />LICENSE I C-42 C-36 OTHER A NUMBER C60 EXPIRATION <br />'Z"), "LO <br />WATER TABLE DEPTH: (JV ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />I PERC TEST # BUILDING PERMIT # D 2455VLAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: I RESIDENCE I COMMERCIAL ) OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: Y NUMBER OF EMPLOYEES' <br />C& SEPTIC TANK TYPE/MFG �� L <br />❑ GREASE TRAP TYPE/MFG <br />DISTANCE TO NEAREST: WELL )J�� <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />CAPACITY <br />CAPACITY <br />ft FOUNDATION 10 <br />❑ PKG TX PLANT <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE 10 ) ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />LEACHING CHAMBERS iNFI r �s / f # OF LINES <br />� <br />LENGTH OF LINES 5 <br />ft <br />Invoice # <br />Permit ID# <br />DISTANCE TO NEAREST WELL 1 1 ft FOUNDATION 10 <br />L(I <br />7� _ <br />ft PROPERTY LINE G -S' '�' <br />ft <br />❑ <br />FILTER BED <br />WIDTH ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ANA. <br />ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />ft <br />a 4N <br />DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />❑ <br />SUMPS <br />WIDTH ft LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />I <br />LI <br />DISPOSAL PONDS <br />WIDTH ft LENGTH <br />ft <br />DEPTH ��✓ <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE IRQv,ry 0047) <br />LZ <br />SEEPAGE PITS <br />NUMBER WIDTH 49" <br />ft DEPTH Z S OEPgRT/A <br />DISTANCE TO NEAREST WELL—i S.->' ft FOUNDATION ZJ ` <br />ft PROPERTY LINE <br />I HEREBY <br />CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNT)' ORDINANCES, <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN <br />COUNTY. <br />HOUR -ADVANCE NOTICE REQUIRED FOR INSPECTIONS - <br />SIGNED <br />Application Accepted By <br />Final Inspection By 4AI '4 <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS <br />TITLE ';�' f LS 'r3t,— / DATE <br />DEPARTMENT USE O L <br />J_ Date Area Employee ID#� <br />Date Z /S I SPECIAL PERMIT - Approv9d by <br />Pit/Sump Soil Character:�- <br />PE <br />Code <br />SC <br />INFO <br />Received <br />he �; <br />Cash <br />Amount to <br />Remitted <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Permit ID# <br />7,127 <br />L(I <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />rA <br />W <br />N <br />(A <br />—J <br />r <br />L <br />