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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 />CALL 209 <br />953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROMDATEISSUED <br />JOB ADDRESS S -5-&q <br />/7 , r�IL• 1-1 ST • <br />CAPACITY <br />f L� L� � �) Z /S <br />CROSS STREET C�IL�itic <br />� <br />�L' /L - <br />{ ✓CjITYIZIP <br />APN l V <br />PARCEL SIZE I <br />OWNER NAME <br />LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />PHON" /7 f' Z � J <br />OWNER ADDRESS l q <br />6. 11-MIZ4,Y i77 <br />CITY/STATE/ZIP <br />J � `' f& Cr -1 J 2 1 > <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />LICENSE C-42 I C-36 OTHER <br />NUMBER <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: C <br />_] PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION <br />PHONE <br />CITY/STAT (� <br />EXPAT ATEIs i ■ <br />.0 <br />Y <br />LAND USE APPLICATION # <br />ENGINEER DESIGNED <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: 1 1 RESIDENCE COMMERCIAL I OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />TERNATIVE <br />❑ <br />SEPTIC TANK TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />s4 �z-2-f <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />FILTER BED WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />It PROPERTY LINE It <br />❑ <br />MOUNDEDr ft LENGTH <br />ft DEPTH ft <br />9 REST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS r11xJ��T ft LENGTH <br />ft DEPTH ft <br />�Q1'JISIA ST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION <br />ft PROPERTY LINE ft <br />I HEREBY <br />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 <br />COUNTY. <br />24 HOUR ADVANCE NOTICE REQUIRED <br />FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br />�MIINIMUM <br />SIGNED <br />�•- <br />TITLE �' 1 i� ,�� <br />2 r <br />/'Z DATE 7 !% , 3 ` / <br />L/DEPARTMENT SEONLY <br />y / /Area -Application Accepted By Date i) <br />Final Inspection By Date 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 />By <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />mit ID# <br />PM IT <br />s4 �z-2-f <br />c, l.s <br />j <br />, vU <br />41 p -5v <br />D 2&4--;�- <br />AL <br />42-01 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />?A- <br />