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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- EFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTION$) EX IRES 1 YEAR FROM DATE ISSUED <br />JOB ADD SS . CITY/ZI}P�/ J <br />CROSS ST T VICILIX �, 1 APP, I a t PARCEL SIZE <br />OWNER NAME <br />OWNER ADDREt s <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />A <br />CITY/STATE IP <br />_ PHOPtif Ej<.� <br />CITY/STATE/ZIP <br />LICENSE I C-42 C-36 OTHER NUMBER 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 REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATI jE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: I I RESIDENCEI COMMERCIAL 11 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 SUTEM) <br />❑ PH LMES LEACHING CHAMBERS # of LINES LENGTH OF LINES ft <br />[�7" 1 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE kIIIIIIIIIIIIIII ft <br />❑ E WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL fl FOUNDATION ft PROPERTY LINE ft <br />❑a -4 U WIDTH ft LENGTH ft DEPTH ft <br />zooDISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ 4MRS�/ WIDTH ft LENGTH ft DEPTH ft <br />Aq rr�ybb�`^I DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />L)DISI4SIL 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 24 HOUR AjDVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED -",-/ Tg Vt✓y `t E /.` /-) /S <br />DEPARTMENT USE ONLY <br />Application Accepted By Date I ( S Area L'1 °' '' Employee ID# 1: �; w <br />Final Inspection By Date 1 SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Permit/ <br />Date Service Request # <br />In ID# <br />�FZ t <br />v <br />uJs <br />P\ <br />I (.;>'-)„ <br />S ) <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />T <br />