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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 A EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS •/ Q LI Or Glen CITY/ZIP <br /> ���� <br /> JJ tin <br /> CROSS STREET I -a dA Oaq APN 0 PARCEL SIZE 4C <br /> OWNER NAME 1 (�(![, �d PHONE Owl- 66 7-c;?41/6 <br /> tai, <br /> OWNER ADDRESSCne_ � CITY/STATE/ZIP <br /> CONTRACTOR 2 /) oPL� PHONE <br /> ' 3cc �S�0a7 <br /> CONTRACTOR ADDRESS a-3/6 DISOoye, CITY/STATE/ZIP Zo dt 59 P <br /> LICENSE ❑YC-42 <br /> ❑0C-36 OTHER NUMBER'qS-EXPIRATION DATE <br /> WATER TABLE DEPTH: J ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: u NEW INSTALLATION REPAIR/ADDITION Li ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL + ❑ OTHER <br /> NUMBER OF LIVING UNITS: moi► NUM13ER OF BEDROOMS: 'r NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY 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 xI LEACHING CHAMBERS O #OF LINES LENGTH OF LINES "/0 ft <br /> DISTANCE TO NEAREST WELL /00 ' ft FOUNDATI0N3 ' 35 ' ft o ft PROPERTY LINE <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 /> DISTANCE TO NEAREST WELL +� ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER - WIDTH J ft DEPTH 057' ft <br /> DISTANCE TO NEAREST WELL/SO ft FOUNDATION 7-'5- ft PROPERTY LINE �O 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 ` 3HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 / <br /> SIGNED TITLE ✓ DATE <br /> _ {v <br /> 1E V <br /> H! <br /> S <br /> N O L NJ <br /> EPA RTMENT SE O Y THpEp AL <br /> Application Accepted By Date ( Area Employee ID#� <br /> Final Inspection By ' Date 2 7 ❑ SPEC AL PERMIT-Approved by <br /> Character of Soil to DeptK of 3 Ft: Pit[5fump Soil Character: <br /> COMMENTS <br /> PE SC Received Checic#/ Amount Date Permit/ Invoice# Permit ID# <br /> CodeINFO B ash Remitted Service Re uest# <br /> 2 �z b 2'1 1 fAft 1 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />