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ONSITE WASTEWATER T REATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 20 <br /> 9 9✓✓53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE(ISSUED <br /> JOB ADDRESS - G G r P %" "� CITYIZIP 5 T14-1111- /F <br /> CROSS STREET A� I Ky`�C /� / _APN / ����/ PARCEL SIZE`/�CION 'r5 o Ga <br /> OWNER NAME IJA VC R l le �!✓``���7 PHH-O�NE! q G 6 0�C/ <br /> OWNER ADDRESS 54�� `�- !+S /I"F'1(I�'�-�--" CITY/STATE21Pc.,���/�iYy ]01 l S'/`` /� <br /> CONTRACTOR( � - PHONE�O / /�6 �/ C� <br /> CONTRACTOR ADDRESS �L/�I'�- � 7 /.7C���" CITYISTATE/ZJP <br /> LICENSE ❑0C-42 110C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # r BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: U NEW INSTALLATION U REPAIRIADDITION U ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG 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 ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <br /> D FILTER BED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE It <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft -- PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARE.D 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 /> UM 24 H R DVANCE N TICS REQUIRED FOR INSPECTIONS <br /> /-PLEASE CALL 209 953-76,9 <br /> SIGNED TITLE t'IJ,y'e./' DATE <br /> � F <br /> O N <br /> A <br /> D -ARTMENT U E�QNY <br /> Application Accepted B Date Area s`•' Employee ID# <br /> Final Inspection By Date ❑ SPE IAL PERMIT-Approved by J <br /> Character of Soil to Dep h of-3 Ft: Pi Sump Soil Characte <br /> COMMENTS <br /> PE SC Received C Amount DatePermit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service uest# <br /> 7 <br /> 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />