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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209) 468.3420 <br />Un—P—INnARI P PFGMIT CALL (209) 953-7697 FOR INSPECTIONS F-XPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS <br />CITY21P <br />CROSS STREET /iLA 1 VAPN PARCEL SIZE �7 <br />OWNER NAME �1 ►�l" r C �'-+�� PHONE a0q �SDq -`7crr)G 1 <br />OWNER ADDRESS CITY/STATEIZIP <br />CONTRACTOR ' , PHONE O -Told' <br />CONTRACTOR ADDRESS CITYISTATE/ZIP <br />LICENSE , C42 , C-36 07HER +Q NUMBER � 4XPIRATION DATE I ,� <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATIONREPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT DESTRUCTION <br />INSTALLATION WILL SERVE: )C RESIDENCE COMMERCIAL OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF ,BEDROOMS: I-� NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG t-tn .A n Y'1••' C. CAPACITY ` lJ Bal # OF COMPARTMENTS'- <br />❑ GREASE TRAP TYPE/MFG CAPACITY 021 # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL 911.),— ft FOUNDATION ft PROPERTY LINE 1--v ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES J it <br />DISTANCE TO NEAREST WELL h FOUNDATION It PROPERTY LINE L ft <br />❑ <br />FILTER BED <br />WIDTH <br />it LENGTH ft <br />DEPTH ft <br />PermlU Invoice # Permit ID# <br />Code <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION <br />ft PROPERTY LINE it <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH h <br />DEPTH fl <br />DISTANCE TO NEAREST <br />WELL It FOUNDATION <br />It PROPERTYLINE ft <br />LK <br />SUMPS <br />WIDTH <br />_ it LENGTH It <br />DEPTH It <br />DISTANCE TO NEAREST <br />WELL it FOUNDATION <br />it PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH <br />ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL it FOUNDATION <br />ft PROPERTY LINE it <br />PITS <br />NUMBER \ <br />I <br />WIDTH II <br />17 <br />C <br />DEPTH It <br />SEEPAGE <br />DISTANCE TO NEAREST <br />s <br />WELL � ft FOUNDATION _ <br />It 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 />DEPARTMENT USE ONLY <br />Application Accepted By Date Area EmployeeID# <br />Final Inspection By Data SPECIAL PERMIT - Approved by <br />Character of Soil to De of 3 t Pit/Sump Soil Character: <br />COMMQ4TS _ <br />C <br />TH <br />PE <br />SC <br />Received <br />Cheek#J <br />Amount Date <br />PermlU Invoice # Permit ID# <br />Code <br />INFO <br />B <br />Cash <br />Remitted <br />Service Re uest# <br />42-01 <br />t or4/07 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />