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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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS `'� �'J^ r/"if <br /> J, s.�,orlJ�'} �- CITY/ZIP_�.,C.-'"',pr1 <br /> CROSS STREET fy�'7 f%b1y'.i�d�u: APN ' ) •)�"+ - yr�{.J '1�— PARCEL SIZE = <br /> c <br /> OWNER NAMEAL/f e fJ Li v'/� �- r(S..Ly I�,r,�. [,�Q,� _ PHONE <br /> v <br /> OWNER ADDRESS J —CITY/STATE/ZIP _ <br /> CONTRACTOR GGtw/... /� ��.Q- �� �l"C . PHONE <br /> _ 2 _ <br /> CONTRACTOR ADDRESS 'GS-7- 7 L4.4/ Z� ,,te�t1 CITY/STATE/ZIP ?,r�"';� '--�►Q 4�L--'i <br /> LICENSE VIC-42 QC-36 OTHER A NUMBER r+C/�1>7� EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> L1 PERC TEST # BUILDING PERMIT# __- LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDrrION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE L. COMMERCIAL fJ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPEIMFG y� �- _ _ CAPACITY 'Z-00 C„j Bal #OF COMPARTMENTS t <br /> GREASE TRAP TYPE/MFG /- 1S CAPACITY t 0 0 gal #OF COMPARTMENTS '�-^ <br /> DISTANCE TO NEAREST: WELLit FOUNDATION S� r'; _._ it PROPERTY LINE .-'0 ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES I LEACHING CHAMBERS ___ #OF LINES ti� LENGTH OF LINES c7 ft <br /> DISTANCE To NEAREST WELL`"it FOUNDATION ft PROPERTY LINE _ ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLit FOUNDATION it PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL11 FOUNDATION ft PROPERTY LINE _ ft <br /> ❑ SUMPS WIDTH ft LENGTH it DEPTH It <br /> DISTANCE TO NEAREST WELL it FOUNDATION ___it PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH--_It LENGTH _.it DEPTH it <br /> DISTANCE TO NEAREST WELL FOUNDATION ft PROPERTY LISLE ft <br /> 1 ! r <br /> SEEPAGE PITS NUMBER �r WIDTH _ fI DEPTH `r ft <br /> DISTANCE TO NEAREST WELL <�y;y,� it FOUNDATION )�� ft PROPERTY LINE—," <br /> INE It <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 /> MMMUM 24 HOUR ADVANCE NOTICE REQUIRED FORINSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED r TITLE_. r DATE ��' ✓ ��L° <br /> i' <br /> LF <br /> H <br /> S <br /> - - - - 7l�- z <br /> — <br /> DEPARTMENT USE ONLY <br /> Application Accepted BY P1 _:_ _ Date `�f/ Areaplo ee ID# <br /> _ Em y <br /> Final Inspection By _ Date [J SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS :ri m Z'4i <br /> PE Sc Received __.Check#/- Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request If <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />