Laserfiche WebLink
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 IiL2'I1. <br />1; �) • <br />GI,1L11W' {IIN <br />CITY/ZIP k9- <br />/ t <br />CROSSSTREET <br />(J� <br />(HI+- <br />i 1 JC fIU 11'� � <br />APN a V o3 o a 1 <br />/ <br />PARCEL SIZE"" ' r <br />OWNER NAME <br />i� �; <br />�C U r 0 YO 1211)72 <br />LEACH LINES <br />PHONE <br />OWNER ADDRESS <br />m't-)/1�, <br /># OF LINES _.rZ <br />CITY/STATE/ZIP <br />LENGTH OF LINES ft <br />(^ <br />CONTRACTOR v��11 <br />�y-,C.l <br />1VZ CM <br />� <br />t LC <br />PHONE <br />(ojq%(d� <br />IS <br />CONTRACTOR ADDRESS 1 s- <br />�PaI�I c�(c;t. <br />CITY/STATE/ZIP <br />'I�Iq,�/O,,1/ G�7 <br />1 w �/ CA 9 ✓ J N <br />ft <br />DEPTH ft <br />LICENSE 1:17-C-42 <br />❑FIC -36 <br />OTHER <br />NUMBER s�I�2S ` EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION X REPAIR/ADDITION I.I ENGINEER DESK <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM 1 ! DESTRUCTION <br />INSTALLATION WILL SERVE: Cj( RESIDENCE ❑ COMMERCIAL j ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ,i NUMBER OF EMPLOYEES: <br />TERNATIVE <br />❑ SEPTIC TANK <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />ft <br />CAPACITY <br />CAPACITY <br />FOUNDATION <br />❑ PKG TX PLANT <br />El <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />' <br />IIS3J�2� <br />Ea 3� <br />M <br />5 <br />LEACH LINES <br />t- LEACHING CHAMBERS <br /># OF LINES _.rZ <br />LENGTH OF LINES ft <br />DISTANCE To NEAREST <br />WELL /_5 Gl ft <br />FOUNDATION <br />S b <br />ft PROPERTY LINE /U ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />It DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />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 />DEPARTMENT U E ONLY p <br />Application Accepted By Date J .wa? J _ Area S / E ployee ID#� <br />Final Inspection By� Date C �'i 0i ( 2�Z b ❑ SPECIAL PERMIT - by <br />Character of Soil to Depth of 3 Ft: \oM Pit/Sump Soil Character: <br />COMMENTS /YJv'v,>1G 14le fz,r f04C/ <br />v <br />PE <br />Code <br />SC <br />INFO <br />Received Check#/ <br />B Cash <br />Amount <br />Remitted <br />Date <br />Permit/ �C (t Permit ID# <br />Service Re uest # Fiy H <br />y�l <br />IIS3J�2� <br />M <br />442-01 <br />/14/16 I I I �� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />v <br />