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ONSITE WASTEWATER TREATMENBT SYSTEM PESRMIT TOCKTON CA 95202-(209)468-3420 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT EXPIRES I YEAR FROM DATE ISSUED <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS <br /> CTIV/ZIP <br /> JOB ADDRESS .Z-O a�4[ <br /> PARCEL SITE o <br /> CROSS STREET <br /> APN <br /> .� // ✓l..__/ PHONE <br /> OWNERNAME <br /> CITY/STATE/ZIP <br /> OWNER ADDRESS PHONE <br /> CONTRACTOR <br /> � (hTVICTATFITIP <br /> CONTRACTOR ADDRESS <br /> Num ER i.e!s26UC EXPiRAT70N DATE <br /> LICENSE m--CC-4� ❑C 36 <br /> OTHER � <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION Coordinates X�— Y <br /> BUILDING PERMIT# /f�M4�� LAND USE APPLICATION# <br /> E3PERC TEST # O ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPAIR/ADDrr1ON <br /> TYPE OF WORK: IDISTALWTION ❑ DESTRUCTION <br /> ❑ REPLACEMENT Ll OTI[ER <br /> ❑ COMMERCIAL <br /> INSTALLATION WILL SERVE: R¢s1DeNce NUMBER OF BEDROOMS: 4 NUMBEROFEMPLOYEes: <br /> NUMBER OF LIVING UNrrs: <br /> CAPACITY Bal #OF COMPARTMENTS 14 _ <br /> C'} SEPTIC TANK TYPE/MFG 5aAcg <br /> CAPACITY gal <br /> #OF COMPARTMENTS <br /> _� <br /> ❑ GREASE TRAP TYPE/MFG /� ft <br /> fj FOUNDATION ft PROPERTY LINE ON S, <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL /W' ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LIFT STATION SIZE TYPEOFPUMP— <br /> LENGTH OF LINES_�'/� ft <br /> LEACH LINES ❑ LEACHING CHAMBERS - PROPERTY LINE ,157 ft <br /> DISTANCE TO NEAREST WELL /5-v ft (} <br /> ft DEPTH FOUNDATION 10' it J <br /> N <br /> ft LENGTH <br /> ❑ FILTER BED WIDTH— ft PROPERTY LINE— ft ;"y <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft <br /> ft LENGTH ft DEPTH <br /> [3 MOUNDED WIDTH ft PROPERTY LINE�—ft Rl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R <br /> LENGTH ft DEPTH <br /> El SUMPS WIDTH ft ft PROPERTY LINE ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it <br /> ft LENGTH ft <br /> ❑ DISPOSAL PONDS WIDTH ft DEPTH PROPERTY LINE�----ft <br /> DISTANCE TO NEAREST WELL_jt FOUNDATION I _ft RI <br /> WIDTH fa I. ft DEPTH ft h <br /> �- SEEPAGE PITS NUMBER <br /> DISTANCE TO NEAREST WELL /�J ft FOUNDATION �: ft PROPERTY LINE,d'I'S V) <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> N <br /> ORDINANCES.STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 cT <br /> TITLE L_-� DATE <br /> SIGNED <br /> 1 <br /> DEPARTMENT U ON Y Empioyec lD# <br /> %L Date 2 U Area <br /> Application Accepted <br /> Date ��5 [3SPECIAL PERMIT-Approved by <br /> �— <br /> Final Inspection B Pit/SDmp Soil Character: <br /> ChanMero(Soll of Ft: <br /> C MMENTS Nr-�) 2.A>T or l <br /> >� Amount Permit/ lavoice# PermitID# <br /> PE SC Received Ch Date Servke oast# <br /> Code INFO B a Remitted <br /> 142.11 �1� y5u'ril) 14 4sD.CAD 28 os a0 <br /> ONSITE WASTEWATER PERMIT <br /> 42-02.001 <br /> I2r22R003 <br />