Laserfiche WebLink
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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ^s CITYIZIP <br /> CROSS STREET ` / / APN D(��-� O PARCEL SIZE (/ ' ✓� <br /> OWNER NAMEy�Iy� �, r ' • (A1110� PHONE <br /> OWNER ADDRESS ?,- . L � +V l JAILeJ) o V CITY/STATE/ZIP r�,,��^'t <br /> CONTRACTOR l_ I LI CA z l/�(l`�I �/ (�� PHONE O`(J -�� �]G�C� (� <br /> CONTRACTOR ADDRESS J( _d s t"�J k� CITY/STATE/ZIP <br /> LICENSE ❑X-42 ❑0C-36 OTHER NUMBER �f�9o�f5 EXPIRATION DATE <br /> f� rl I <br /> WATER TABLE DEPTH: V �y ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED(ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ,/ 11 OTHER <br /> NUMBER OF LIVING UNITS: {� NUMBER OF BEDROOMS: L11. NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG KI ✓1 y CAPACITY Zoo o 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 % ft <br /> �0 <br /> DISTANCE TO NEAREST WELL ASO 7L 1f FOUNDATION 'VO 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 ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft 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 ft LENGTH ft DEPTH ft <br /> / SEEPAGE PITDISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> S NUMBER -7 WIDTH �5 ft DEPTH <br /> r ft <br /> DISTANCE TO NEAREST WELL %SL7 Y ft FOUNDATION ft PROPERTY LINE `fO 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 /> MINIMUM 4WHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br /> SIGNED TITLEOI. e'C r DATE /O— 25 -'/V <br /> 1 <br /> 1 <br /> 2EPARTMENTIUSE kjL <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Dqw0f 3 it/ mp oil Character: <br /> COMMENTS <br /> PAYMENT <br /> PE SC Received hec Amount Permit/ <br /> Code INFO B ash emitted Date Service Re uest# Invoice# 7Permit <br /> SAN JOAQUI OU TY <br /> ENVIRONMENTAL <br /> 42-01 ONSITE WASTEWATER TFffM' 19WATIffNT <br /> 4/24/12 <br />