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f 0 <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 <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />LICENSE 1111C-42 ❑❑C-36 OTHER <br />9b3-109/ FOR INSPECTIONS LXPIRES 'I YEAR FROM DATE ISSUE <br />> t CITYIZIP C <br />_ APN I j L(/�/� • 2� PARCEL SIZE D .05 <br />A PHONE 510 Z-�i U f <br />PHONE 5,-,/L� �-94— 7-3 <br />CITY/STATE/ZIP <br />NUMBER EXPIRATION DA <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 IALTERNAT E <br />11 REPLACEMENT El❑ OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />0 <br />INSTALLATION WILL SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL <br />❑ OTHER <br />ft <br /># OF LINES <br />NUMBER OF LIVING UNITS: <br />NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />ft DEPTH <br />❑ <br />SEPTIC TANK TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />ft <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />❑ LEACHING CHAMBERS <br />ft PROPERTY LINE <br />ft <br /># OF LINES <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft DEPTH <br />ft <br />FOUNDATION_ <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />_ft DEPTH <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 />LENGTH OF LINES <br />ft <br />ft PROPERTY LINE <br />ft <br />ft DEPTH <br />ft <br />ft PROPERTY LINE <br />ft <br />ft DEPTH <br />ft <br />ft PROPERTY LINE <br />ft <br />ft DEPTH <br />ft <br />ft -` PROPERTY LINE <br />ft <br />ft DEPTH <br />ft <br />ft PROPERTY LINE <br />ft <br />_ft DEPTH <br />ft <br />ft PROPERTY LINE <br />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 />5� <br />PE <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />emitted <br />Date <br />Permit/Code <br />Service Request # <br />Invoice # Permit ID# <br />Z. <br />?,/13 <br />3 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />