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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�/ s1 <br /> 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ` ,( �� ✓�t CITY/ZIP i-rr / <br /> c,r CST �� <br /> CROSS STREET _ �l�/ APN '� �/� PARCEL SIZE._ <br /> v <br /> 1 A <br /> OWNER NAME PHONE <br /> OWNER ADDRESS `I 72 CITY/STATE/ZIP p—/4c:%/ C <br /> CONTRACTOR M ` S ��1+[.{e, �, { P PHONE <br /> CONTRACTOR ADDRESS -CITY/STATE/ZIP y/ ►�I��G 1�-/� 5 /9 <br /> LICENSE ❑CIC-42 ❑1IC-36 OTHER NUMBER&-C&dg!W EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: U NEW INSTALLATION REPAIR/ADDITION U ENGINEER DESIGNED/ALTERNATIVE <br /> CI REPLACEMENT U OUT-OF-SERVICE SEPTIC SYSTEM 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL I7 OTHER <br /> NUMBER OF LIVING UNITS: nn NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> d SEPTIC TANK TYPE/MFG 'PSL CAPACITY gjfS;PqU _ gal #OF COMPARTMENTS_ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION C h1 ft PROPERTY LINE -7S 1- ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP 2 PKG TX PLANT 0 SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> f <br /> LEACH LINES U LEACHING CHAMBERS #OF LINES Li LENGTH OF LINE:, r fl <br /> DISTANCE TO NEAREST WELL, ft FOUNDATION .D 1 ft PROPERTY LINEft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 /> MINIMUM 48 HOUR ADV CE REQUIRED FOR INSPECTION�S-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE��(f-1/ ����r DATE <br /> JOA <br /> rVV R C <br /> P <br /> T <br /> PARTMENT JfSE NLY <br /> Application Accepted B Date Area Employee ID# <br /> Final Inspection By SSSS Date 11 SPE IAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS S <br /> V . <br /> ` h2c 762Mh S . <br /> PE Sc Received (Check5V Amount Permit/ <br /> Code INFO B emitted Dat Service Request Vr# Invoice# Permit ID# <br /> L <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/13 <br />