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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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEARFROMDATE ISSUED <br /> JOB ADDRESS ^ �O CITY/ZIP < <+ ` 4v <br /> fl <br /> CROSS STREET c�`t'. �w APN Z "�/4 V PARCEL SIZE 3 p <br /> 7byy <br /> OWNER NAME Qi 'C r' PHONE <br /> OWNER ADDRESS CITYISTATEIZIP �C <br /> CONTRACTOR <-L.�S c�cr PHONE l j`J(' �12'J4 <br /> _ C <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE DOC-42 110C-36 OTHER NUMBER 4�tj`5.)�� EXPIRATION DATE <br /> WATER TABLE DEPTH:A!AZ f ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE PLICATION# <br /> TYPE OF WORK: Li NEW INSTALLATION EPAIRIADDITION u ENGINEER DESIGNED 1 QVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM/❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: kLYf ESIDENc`E ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EmPLOYEEqjC:!"� <br /> ❑ SEPTIC TANK TYPE/MFG \ CAPACITY gal #OF COMP/�{j,TMENTS 20m <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPAR�QU <br /> DISTANCE TO NEAREST: WELL ft FOUNDA ON ft PROPERTY�lt�TH nN7Al <br /> ❑ LIFT STATION SIZE TYPE OF PUMP \ © PKG X PLANT ❑ SAND OIL SEPARATOR(ENCLOSED.-;y <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL FOUNDATION ft PROPERTY LINE ft <br /> FILTER BED WIDTH t�,' ft LENGTH I ft DEPTH_ai I ft <br /> DISTANCE TO NEAREST WELL7LENGTH <br /> FOUNDATION (f7I-F ft PROPERTY LINE S '� ft <br /> ❑ MOUNDED WIDTH ft ft DEPTH ft <br /> DISTANCE TO NEAREST WELL FOU ATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ff ft DEPTH ft <br /> DISTANCE TO NEAREST WELL FOUNDATI I ft -- PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft ENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST W L 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 THI APPLICATION AND THE WORK WILL BE DONE IN ACCO ANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STAT LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN DUNTY. <br /> MINIMUM `{ HOUR ADV CE NOTICE REQUIRED FOR INSPECTIONS- EASE CALL 209 95 7697 <br /> SIGNED TITLE 'S 4✓ DATE <br /> Of <br /> EPARTMENT UYE OA&Y <br /> Application Accepted By Date Area Employee ID#I <br /> Final Inspection By Date ❑ SPE IAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit1SLjrnp Soil Character: <br /> COMMENT V IAa 2 � � � ,, b _ <br /> PE SC Received _kqbggj6W Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Cash Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />