Laserfiche WebLink
ki <br />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 -n EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS � ( Z pt1 l (T rLD CITY/ZIP V Y C' ✓b4:" I GRA <br />CROSS STREET� { t Irr�� �S V APN % 77 LJ PARCEL SIZE <br />OWNER NAME • �/yy1 OU l d 6("k -'C- f- (nrc p )a A PHONE <br />OWNER ADDRESS,, CITY/STATEIZIP <br />/ <br />CONTRACTOR V h f I�__ A c 44 G 4 a -G �G' r- PHONE 4 SG - SSU r q <br />CONTRACTOR ADDRESS �j6p l( �L� CITY/STATE/ZIP�d-eG� 1G✓I L,��0 <br />LICENSE ❑LC -42 ❑CIC -36 OTHER ILL NUMBER(.P�„099" EXPIRATION DATE <br />0 <br />WATER TABLE DEPTH: U 0-30 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: 1) NEW INSTALLATION ? I I REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT I f�fGel { R I t ( ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: a NUMBER OF EMPLOYEES: <br />❑ <br />SEPTIC TANK <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />ya)o <br />�s <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />FI LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />DISTANCE To NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />FILTER BED <br />WIDTH Ing ft LENGTH <br />L1ff1 ft DEPTH ( p fI ft <br />DISTANCE TO NEAREST WELL 5Z <br />1 ft FOUNDATION 1 O 1 ft PROPERTY LINE JC)/ ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />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 <br />tIOUR ADVANCE NOTICE REQUIRED <br />FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED44546�TITLE <br />45-n iN t� /�K-'F'� i_ DATE allfs a <br />DEPARTMENT SE ONLY <br />Application Accepted By '�� Z` Date d Area Employee ID#—LL`Z <br />Final Inspection By� Date \1-_) 1 (0 [ j5DZ� ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS FXl��in� )PvG(1 lines -10 be r�b�NC-YIr� (Ind iPblelted �z ea, <br />Soak <br />PE <br />Code <br />SC <br />INFO <br />Received heck# <br />By ash <br />Amount <br />Remitted <br />ate <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />ya)o <br />�s <br />ll <br />3- <br />T <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />AA <br />