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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 CALL 209 953-7697 FOR INSPECTIONS XPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 9 V <br />CITY/ZIP . "7 7 <br />CROSS STREET ll Yom. LL- A P N C +� 5,0 _ PARCEL SIZE _0 <br />OWNER NAME ew%. IZ if aee It, V tu S PHONE _ ,J �C <br />OWNER ADDRESS 1,02- � ~ CITY/STATE/ZIP J / J_ G/V{ A � // z <br />CONTRACTOR //V _��' 14 c' ' PHONE 2-09 %Z__ "IV z </' <br />CONTRACTOR ADDRESS L� <br />�,Y �S•�.h1Q� <br />V <br />CITY/STATE/ZIP <br />LICENSE ❑OC -42 ❑❑C-36 OTHER <br />NUMBER <br />CA ITY <br />EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFOIRAAlITNT— Coordinat X _ Y <br />❑ PERC TEST # ] BUILDING PERMIT # V V jq USE APPLICATION #-- <br />TYPE <br />_TYPE OF WORK: ❑ NEW INSTALLATION LI RrMM DITION LI ENGINEER DESIGNED/ALTERNATIVE <br />❑ REPLACEMENT P OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: _I RESIDENCE I COMMERCIAL / ❑ OTHER 7�IGI <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ` ' NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal It OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CA ITY <br />gal ff OF COMPARTMENTS_ <br />DISTANCE TO NEAREST: WELL <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />I I LEACHING CHAMBERS <br />ReceivedCheck# <br /># OF LINES <br />LENGTH OF LINES <br />Permit/ <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />9 PROPERTY LINE <br />❑ FILTER BED <br />WIDTH ft <br />LENGTH <br />f <br />DEPTH <br />DISTANCE TO NEAREST WELL <br />It <br />FOUNDATION <br />ft PROPERTY LINE <br />❑ MOUNDED ft <br />LENGTH <br />_ <br />i ft <br />DEPTH <br />Y E R T WELL <br />ft <br />FOUNDATI <br />ft PROPERTY LINE <br />❑ SUMPS I ft <br />F-'l�l1STANj"R <br />LENGTH <br />ft <br />DEPTH <br />WELL <br />ft <br />F NDATION <br />ft PROPERTY LINE <br />❑ DISPOSAL PONDS <br />WIDTH ft <br />LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />It PROPERTY LINE <br />I HEREBY CERTIF)�THAT I HAV REPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />/ STATE LAWS AND RULES AND REGULATIONS OF SAN JOAOUIN CO NTY. <br />NIMU 2 HOUR DVANCE NOTICE REQUIRED FOR IN CTI ASE CALL 209 953-J697 f <br />SIGNED / TITLE DATE �7 <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />�—� IIFPdRTMFNT IUSF nNLY SAID j Aftt6 <br />Application Accepted By Date _�_ Area t F_m I9P q UN <br />Final Inspection By Date r1 SPECIAL PERMIT - Approve �tl N <br />Character of Soil to Depth of 3 Ft: _ Pit/Sump Soil Character: A M�"._ <br />COMMENTS \v t�Zlvl& <br />PE <br />SC <br />ReceivedCheck# <br />Amount <br />Da a <br />Permit/ <br />PFR <br />rmit ID# <br />I <br />Code <br />INFO <br />Cash <br />Remitte <br />Service Request # <br />�Oa- l <br />�'' <br />�-r �5 <br />��c% <br />iEXIF111*0 <br />V <br />% <br />- <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />T <br />-j <br />m <br />Y <br />x <br />m <br />