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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 <br />mss' <br />— i 5 ft GEOGRAPHICAL INFORMATION: Coordinates X <br />G.9ALL Z y53-/dy/ FOH INSPECIIUNS <br />I HUM AI t I,JUtl <br />- APII/HIttCU <br />C1 <br />JOB ADDRESS' lL 1 <br />.1 <br />LAND USE APPLICATION # <br />)TtAH <br />//5 <br />TI� <br />/ <br />NEW INSTALLATION <br />LCCITY/ZIF✓ <br />d �/ <br />ENGINEER DESIGNED/ALTERNATIVE <br />CROSS STREET I _! cai11 G <br />�!� _ <br />APN \� \ <br />PARCEL SIZE <br />OWNER NAME Z�'+Ltl� S <br />Irl C= K l y <br />INSTALLATION WILL SERVE: RESIDENCE <br />PHONE <br />OWNER ADDRESS 1-13 I J, <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />LICENSE ❑ C-42 I : C-36 OTHER <br />CITY/STATE/ZIPC� <br />�/QC/ <br />_ PHONE %.O ( ' `� / / 3-3,4""-1 C <br />CITY/STATE/ZIP I �� L1 n Cc,, <br />NUMBER EXPIRATION DATE <br />U <br />WATER TABLE DEPTH: <br />mss' <br />— i 5 ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />Amount <br />PERC TEST # <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />Code <br />TYPE OF WORK: <br />NEW INSTALLATION <br />REPAIR/ADDITION <br />ENGINEER DESIGNED/ALTERNATIVE <br />Se .'ce Request # <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION r T A/ <br />INSTALLATION WILL SERVE: RESIDENCE <br />; COMMERCIAL <br />OTHER <br />NUMBER OF LIVING <br />UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG _ _ <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ LIFT STA; <br />SIZE TYPE OF PUMP <br />LlPKG TX PLANT LI <br />SAND OIL SEPARATOR (EN LOSE SYSTEM) <br />- <br />�- - <br />❑ LEA <br />f I LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ FWIDTH <br />_ ft LENGTH <br />ft <br />DEPTH _ <br />ft <br />13AQN <br />111��� <br />DISTANCE TO NEAREST WELL <br />WIDTH ft LENGTH <br />ft FOUNDATION <br />ft <br />ft PROPERTY LINE <br />DEPTH <br />ft <br />It <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS <br />WIDTH ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />It DEPTH <br />ft <br />DISTANCE To NEAREST WELL <br />It FOUNDATION <br />ft PROPERTY LINE <br />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 <br />OF SAN JOAQUIN COUNTY. <br />MINIMU <br />24 HOUR ADVANCE NOTICE REQUIRED FORINSPECTIONS- PLEASE CALL 209 953-7697 <br />SIGN <br />/7 _/T <br />TITE <br />DATE: <br />r <br />DEPARTMENTUSE O LY <br />Application Accepted By _ Date Area Employee ID# <br />Final Inspection By _ Date ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS r-iQop .c: '4"' .,c nUrcrs.--r%tc;xa- i <br />PE <br />SC <br />Received Check#/ <br />Amount <br />Permit/Date <br />Invoice # �, ,. Permit ID# <br />Code <br />INFO <br />B Cas <br />Remitted <br />Se .'ce Request # <br />42-01 ; 4 t ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />'1 < 4 <br />'i it <br />