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ONSITE WASTEWATER TTMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL209 9 3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRO ATE ISSUED <br /> r C�y <br /> JOB ADDRESS / mal�y� CCS BGG ' CITY/ZIP <br /> CROSS STREET � �D ` [� GAPN '3 c120Z0 oZ77 PARCELSIZE <br /> O <br /> lc 11 "44,16"§A5 <br /> OWNER NAME Q PHONE <br /> OWNER ADDRESS /i'� /�� CITY/STATErzIP <br /> CONTRACTOR A1V "' PHONE / <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE I C-42 U 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: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERN TIVE_ <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM ) D)t DESTRUCTION 4.KJ L IGLip' <br /> INSTALLATION WILL SERVE: RESIDENCE I COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTICTANK TYPE/MFG _ CAPACITY gal It OF COMPARTMENTS <br /> ❑ GREASETRAP TYPE/MFG _ _. _ CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL It FOUNDATION it PROPERTY LINE It <br /> ❑ LIFT STATION SIZE TYPE OF PUMP C1 PKGTIC PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ___ It FOUNDATION it PROPERTY LINE It <br /> ❑ FILTER BED WIDTH '�Itt LENGTH _ it DEPTH <br /> DISTANCE TO NE R'''���111T r. yety I Ff N � PROPERTY LINE ft <br /> ElMOUNDED WIDTH L t DE ft <br /> DISTANCE TO NEAREST LLQ ft F TO PROPERTY LINE ft <br /> ❑ SUMPS WIDTH _ �(m�m(�� iLLiEr�T,7F� NW-j`y`DEPTH ft <br /> DISTANCE To TO NE�INEL�LI• "'M ( �}j�� uR PROPERTY LINE ft <br /> WIDTH .."nil <br /> ❑ DISPOSAL PONDS DISTANCE TO NEMEST WE � I OUN6A�kt� PTH It <br /> PROPERTY LINE It <br /> ❑ SEEPAGE PITS NUMBER rel( 11(t Q i DEPTH ft <br /> DISTANCE TO NEAREST�-Y WELL It FOUNDATION ft PROPERTY LINE It <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:HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED r4'- _ _ TKE 6(,rw __ DATE- <br /> - w <br /> Ov <br /> lz <br /> QUA <br /> I <br /> 6 <br /> s� <br /> c /�yyJ/JJ.. ]]q� IP Nt <br /> DEPARTMENT U NLY C� <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By Date E SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> OMMENTS ✓'w LI lav - <br /> q <br /> PE SC Received Check#/ Amount PermiU <br /> Code INFO B s Remitted Date Service Request# Invoice# Permit ID# <br /> ZZl u os,� a•1ap K P 0 0 z <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />