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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />PION -REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />aJOB ADDRESS t _ lCITYRIP <br />CROSS STREET APN I yW O r,PARCEL SIZ7]E�y /,4-3 <br />I / <br />OWNER NAME V PHONE `7 ill / L. % <br />OWNERADDRESS S Seat/ CIE�s AI CITY/STATE/ZIP <br />CONTRACTOR 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: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIG ED /ALTERN611VE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />CAPACITY <br />CAPACITY <br />ft FOUNDATION <br />❑ PKG TX PLANT <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />T <br />❑ LEACH LINES J LEACHING CHAMBERS <br /># OF LINEs LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ FILTER BED WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ MOUNDED WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SUMPS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION 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 <br />REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED <br />TITLE n )C— DATE �i — 13 ^ —V O <br />e <br />Application Accepted <br />Final Inspection By_ <br />Character of Soil to D <br />COMMENTS ii <br />DEPARTMENTAISEDNLY <br />Date f.j Area Employee ID#� <br />Date l ❑ SPECIAL PERMIT - Approved by <br />3 Pit/S'S o*1 Charact : <br />r � <br />Oil— i, IA J'A0 r- v I, f ,4 A In P <br />PE <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date Service Request # Invoice # <br />Permit/Code <br />Permit ID# <br />21�-771 <br />Z <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />