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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET - STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL (209) 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS O <br />CAPACITY <br />CITY/ZIP <br />7 . "Ji 7 4 <br />[ <br />CROSS STREET b2 j el/'�%� <br />? <br />APN �J <br />y�T <br />�� w� <br />PARCEL SIZE <br />^C1 <br />j7 <br />�j <br />a � C <br />OWNER NAME/yc t kk -/ <br />CAPACITY <br />PHONE <br />OWNER ADDRESS <br />/{J ` �J <br />CITY/STATE/ZIP <br />DISTANCE TO NEAREST: <br />CONTRACTOR ����%?`� �� <br />L�s� <br />PHON <br />CONTRACTOR ADDRESS lot <br />irt-va - / <br />CITY/ST TE/ZIP <br />SIZE TYPE OF PUMP <br />LICENSE EIC -42 JC -36 OTHER NUMBER A?• U EXPIRATION DATE 4 �l <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 c ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM IJK DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE 7 COMMERCIAL ❑ bTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />�Gati-JEPTIC TANK <br />TYPE/MFG <br />ReceivedCheck#/ <br />B <br />Cash <br />CAPACITY <br />Date <br />gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WE� <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft7 L <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />t�V!C�t <br />FOUNDATION <br />ft PROPERTY LINE ft <br />C3 <br />SUMPS <br />WIDTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />F NDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS <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 />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft 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 />& RCM40] <br />Application Accepted Date %%O� �'u/UArea ✓i Employee ID# <br />Final Inspect. Date ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS .712. <br />PE <br />Code <br />SC <br />INFO <br />ReceivedCheck#/ <br />B <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/I <br />Service Request #rt <br />Permit ID# <br />.4 11TEr <br />�J` �c rt-� <br />--as -AL -AL WiJB.J <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />6/26/09 <br />