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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 />[VON-KEFUNr ILE PERMIT <br />CALL (2209) 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUE[ <br />[� <br />JOB ADDRES: C / 7 ' <br />Q, ' i ! <br />CITY/ZIP / <br />r / I <br />> !� �� %,o <br />CROSS STREET OLt/ <br />T <br />n" , <br />�v APN <br />�� _ <br />PARCEL SIZE�� Z <br />OWNER NAIL <br />Remitted._ <br />Date <br />Service Request # <br />OWNER ADDRESS� Q j'rYj/ <br />(rte `--eA— <br />CITY/STAT/ZIP <br />CONTRACTOR <br />l o <br />PHONE <br />moo 73 03 <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE I C-42 C-36 OTHER <br />NUMBER <br />EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # I BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNgTIVIE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM X DESTRUCTION C " I - n6 <br />INSTALLATION WILL SERVE: I ! RESIDENCE ! COMMERCIAL Vf 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 COMPARTMOS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLQB! S1515Y M) <br />❑ LEACHeLlgNES(LEACHING CHAMBERS # OF LINES LENGTH OF LINES <br />III,��TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ F � ft LENGTH It DEPTH <br />It <br />ISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 1r:4. ft <br />❑ M WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE �F p ft <br />❑ SUMPS WIDTH ft LENGTH ft DEPTH S.61 (J� ft <br />DISTANCE TO NEAREST WELL f FOUNDATION ft PROPEFyrY LftZEBft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH /C�L)lf IJIffj w•7 ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE jWAIr ft <br />❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />[ 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 />SIGNED <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Depth of 3 <br />COMMENTS IQ I I,, <br />Z, <br />D FORINSPECTIONS - PLEASE CALL (209) 953-7697 <br />_ TITLE /tZN/I/"l� DATE y iF !`,� <br />DEPARTMENT U E ONLY <br />Date l i Area I Employee ID# <br />Date *.J SPECIAL PERMIT -Approved by <br />Pit/Sump Soil Character: <br />PE <br />SC <br />Received <br />Check#1 <br />Amount <br />Permit/ <br />Code <br />INFO <br />B <br />Cash <br />Remitted._ <br />Date <br />Service Request # <br />Invoice # Permit ID# <br />zv( <br />/ <br />l o <br />.­ <br />moo 73 03 <br />y <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />