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IG <br /> ` ONSITE WASTEWATER`Vk-ATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT jV CALL 209 9 3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRO ATE ISSUED <br /> JOB ADDRESS CITY/ZIP Shx/lr-e, <br /> ren <br /> CROSS STREET G APN 12 d4'a7()CZ PARCELSIZE /2—�C. p <br /> OWNER NAMEA le 4 a PHONE <br /> OWNER ADDRESS ZSR �� < <� CITY/STATE/ZIP 5-iz <br /> CONTRACTOR A/0 O "' PHONE <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: I NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION I `wwY <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE U COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE 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 It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 /> M/ UM.24 R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED T E 6�' <br /> Jill <br /> 6 <br /> n <br /> v4- <br /> NT <br /> DEPARTMENT USE ONLY HEAD-T <br /> Application Accepted By,/ Date, Area q� Employee ID# 5 S"J--- <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Piv p Sit Character: <br /> >-3 <br /> COMMENTS `ltv <br /> 5 0 V r -1 <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B Cash Remitted Date I Service Request# Invoice# Permit ID# <br /> zZt o1 y``' i a1 I(�IRDU7S2�1 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />