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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 CAL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Cis <br /> JOB ADDRESS �- �% CIT2;1YIP � ..� <br /> CROSS STREET ' APN_ �� I PARCEL SIZE D • p <br /> r :7- l <br /> OWNER NAME �(/1/�/� �'� PHONE -5 <br /> OWNER ADDRESS O /1 CITY/STATE/ZIP ��t• <br /> �Gl,-^ / T/Ii.�2/�i ��/ Q� Li.�✓f PHONE?,L7=' L/ 1 <br /> CONTRACTOR ,��/,{� <br /> CONTRACTOR ADDRESS /C/7 T � ✓ h CITY/STATE/ZIP <br /> LICENSE '[�C-42 - OTHER NUMBER EXPIRATION DATE ----:7 oz-'a <br /> WATER TABLE DEPTH:Aa 7ra ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION IGG/- REPAIR/ADDITION ENGINEER DE IGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL LI OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG 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/--1� ft FOUNDATION ft PROPERTY LINE _ ft <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 yft FOUNDATION It PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH 7 J ft DEPTH Z � ft <br /> DISTANCE TO NEAREST WELL d ft FOUNDATION ft PROPERTY LINE It <br /> 1 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 24 HOUR ADVAN E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 J <br /> SIGNED _ TITLE DATE <br /> J ,U <br /> R CUry <br /> We D p A <br /> r <br /> EPARTMEN USE NL <br /> JA Application Accepted y Date Area Employee ID# <br /> Final Inspection By Date ❑ SPE IAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Pit/ Soil Character: <br /> COMMENTS <br /> z�t) a- <br /> P9 SC Received Chec Y Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Ay, - sh Remitted Service Request# <br /> r. <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />