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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 11 CALL 209 -7697 FOR INSPECTIONS EXPIRES 9 YEAR FROM DATE ISSUED <br /> JOB ADDRESS L l C -J CITY/ZIP GA C Cj� y <br /> CROSS STREET r // 1 APN G.- �' ' PARCEL SIZE f�• p <br /> OWNER NAME 7/' l'I C � iL PHONE <br /> r m <br /> s7 � <br /> OWNER ADDRESS? � ��✓ CITYISTATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE ❑1-IC-42 ❑❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH:-Ib ft GEOGRAP ICAL INFORMAT ON: COO dinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# - LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION Li R PAIR/ADDITION Lj ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION r <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BED MS: NUMBER OF EMPLOYEES: /J <br /> SEPTIC TANK TYPE/MFGim CAPACITY gal #OF COMPARTMENTS - <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION I (� ft PROPERTY LINE t;'--f ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES n LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> FILTER BED WIDTH L-1 ft LENGTH 1 ft DEPTH ft <br /> DISTANCE TO NEAREST WELL Go ft FOUNDATION V -I- ft PROPERTY LINE f 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 /> 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 /> MINIMUaURA4XANCE NOTICE REQUIRED FOR INS ECTIONS - PLEASE CALL 209 956-7697 <br /> SIGNE ZJTITLE �/ L�� DATE <br /> T <br /> 14 <br /> S <br /> NION <br /> Ogxry <br /> H E C <br /> EPARTA/IENT L!SE O LY <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By &*0 Date ❑ SPEC AL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE Sc Receivedheck# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitteq rvice Re nest# <br /> lll� b " <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />