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' r <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> KION-REFUNDABLE PERMIT CALL(209),953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS J CITY/ZIP <br /> / H <br /> CROSS STREET APN/i PA CEL SIZE �y <br /> OWNER NAME G ` PHONE Jh <br /> OWNER ADDRESS 01 CITYI TATE/ZIP , VV <br /> CONTRACTOR I I—C #L r C PHONE <br /> CONTRACTOR ADDRESS 1 / �� l�l� �"J/ CITY/STATEIZIP �✓l. ��/.i. �J �l <br /> LICENSE 110C-42 110C-36 OTHER NUMBER / EXPIRATION DATE <br /> WATER TABLE DEPTH: A ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: U NEW INSTALLATION U REPAIR/ADDITION U ENGINEER DESIGNED/ALTERN TIVE J <br /> REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM _1k DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: / NUMBER OF EMPLOYEES: <br /> 'EL SEPTIC TANK TYPE/MFG ACAPACITY 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 lif—TYPE OF PUMP ❑ PKG TX PLANT L2 SAND OI SEPARATOR( NCLOSED SYST ) <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 ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH Arr ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERT I ft <br /> ❑ SUMPS WIDTH fl LENGTH ft DEPTH� J� ft <br /> RTY`CX <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft -- PROPEft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH _S-AFN� ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PR dYVl'w N CO ft <br /> LlSEEPAGE PITS NUMBER WIDTH fl DEPTH LTH pE TAL ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE T 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 HOURADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE ��f � DATE e' <br /> c <br /> P A R T M E N T 0 SE 4.L.Y <br /> Application Accepted By Date AreaEmployee ID# <br /> Final Inspection By"4k1**-- v Date 11SPE IAL PERMIT-Approved by <br /> Character of SoiNoA(4a&T.-v <br /> th of 3 Ft: PiVS mp Soil Character: <br /> COMMENTS pw"(z zma IDT- DUMP T ,, diem luy - oil <br /> V pn��'•�( purv►r �g�r��X� v►� y ii✓ q,ns� ayeQslr� Wl��+�9►�- ?�i2//9 /���tY�� <br /> PE SC Received he Amount Date Permit/ Invoice# Permit ID# <br /> Code INFOB Cash Remi ed Service Re uest# <br /> 6�11 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />