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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 /> NON-REFUNDABLE PERMIT CALL 209 95.3-7697 FOR INSPECTIONS EXPIRESQ 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 4'rY�? 1(` h-' CITY/ZIP ^ <';y :LSV> J H <br /> A <br /> CROSS STREET mqa "Ct i APN PARCEL SIZE �. l 7 d <br /> b <br /> OWNER NAME -rA t opt <br /> �'pt 1 PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP L <br /> CONTRACTOR Y I I �L P I� �7 ?C( tJ �'E' ' PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑0C-42 110C-36 OTHER-_-1 NUMBER iS � EXPIRATION DATE (.?y <br /> -7 <br /> WATER TABLE DEPTH:,%V 42 0 ft GEOGRAPHICAL INFORMATION: COOrdin teS X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: U NEW INSTALLATION REPAIR/ADDITION U ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: Lar RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> �/1 n <br /> SEPTIC TANK TYPE/MFG Taj-L CAPACITY J-4 gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL inc) ft FOUNDATION '.h y ft PROPERTY LINE `10/ 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 /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> FILTER BED WIDTH '1O 9 ft LENGTH 100 ft DEPTH // ft <br /> DISTANCE TO NEAREST WELL (�o I ft FOUNDATION (O ft PROPERTY LINE .S 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 AAS ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> �n,� <br /> ❑ SEEPAGE PITS NUMBER WIDTH f( DEPTH ` / 0 _ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE J� <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN C <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. pyRTTq� <br /> MINIMUM q&HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 MFNT <br /> SIGNED TITLEC,,b/L f- DATE <br /> I r- •� r <br /> I <br /> C� <br /> 1 <br /> 1 ' r <br /> 7 <br /> '1DEPARTMENT1JSE10XLY <br /> Application Accepted By ���� Date Area Employee ID# <br /> Final Inspection By U e7 Date ❑ SPE AL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sunil)Soil Character: <br /> COMMENTS 01w dg44`L 761,Nk- 5 /M� Fr�l� 4114 665� <br /> PE SC Received Checl Amount Permit/ <br /> Code INFO B s emitted Date Service Request# Invoice# Permit[Dg' <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />