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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 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP 72-an V �G v <br /> CROSS STREET `Q�l (/l� A P N I�( PARCEL SIZE yds <br /> OWNER NAME 11 c c I / lJ� V/ C� <br /> (� PHONE (�/r�/ �22(} (�J�C/ ren <br /> OWNER ADDRESS n//( aC- !� C- CITY/STATE/ZIP (�e�YIDGINI� Cal i63F <br /> CONTRACTOR / -Tarr ktn4 1"L'2 all2 LJ Cwt�- PHONE ao�/ I�,��0 OD � <br /> CONTRACTOR ADDRESS ,CD3 /1-0a;i A"'Ae CITYISTATEIZIP �!'( �S O �j a gSJ75� <br /> LICENSE 011C-42 Z'❑C-36 OTHER NUMBER (J��� l EXPIRATION DATE <br /> WATER TABLE DEPTH: (� / ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: LJ NEW INSTALLATION Li REPAIR/ADDITION Li ENGINEER DESIGNED/ALTERNATIVE <br /> D REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: VJ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: z NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> Zf SEPTIC TANK TYPE/MFG CAPACITY Z,-q 06 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 /> 0' LEACH LINES ❑ LEACHING CHAMBERS #OF LINES 3 LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY I WE ft <br /> FILTER BE y WIDTH ��C2 ft LENGTH ft DEPTH 24- — ? ft <br /> DISTANCE TO NEAREST WELL )n' ft FOUNDATION C1 ft PROPERTY LINE 10L <br /> 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 /> DISTANCE TO NEAREST WELL 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 /> 1 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 /> M1N1WJj4A10/HOUR 4DMNCE NOTICE REQUIRED FOR WSPECI NS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> J <br /> H 0 U Ty <br /> UEP <br /> 'dlybit <br /> tenT <br /> DE ARTMENTUSE Y <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By Date L ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to epffi of 3 Ft: Pit/Su p Soil Character: <br /> COMMENTS <br /> PE SC Received Checlt#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO as Remitted Service Re uest# <br /> 77 (5� <br /> 42-01 2,� / ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />