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'1 <br />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 <br />PERMIT CALLS 1209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS �\ Cs I > %n /41� —CITY/ZIP <br />Z C �`�� / )' C/J �Z I LAp 7��1 r7 <br />CROSS STREET R j , l e �� r1 APN �� Z. U PARCEL SIZE- n/ o <br />OWNER NAME iG HCt1 A rA) C -51i �. T PHONE 2 -ori — L(c/S '-L'p J - <br />OWNER ADDRESS CITY/STATE/ZIP <br />CONTRACTOR <br />CONTRACTOR ADDRESS CITY/ A <br />LICENSE C-42 C-36 OTHER NUMBER A <br />EAr <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # ' i ✓13 i • LAND USE APPLICATION # - ✓v'v <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/gLLTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION ��C L �C' ✓L <br />INSTALLATION WILL SERVE: I RESIDENCE COMMERCIAL U OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />4' 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 SYSTEM) <br />❑ LEACH LINES LEACHING CHAMBERS # OF LINEs LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH f H ft DEPTH ft <br />DISTANCE TOT ft FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS WIDTH ft DEPTH ft <br />N <br />DISTANCE TO f T ft FOUNDATION ft PROPERTY LINE ft <br />LlDISPOSAL 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 />SIGNED <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS T-,, I <br />DEPARTMENTUSE QNLY / <br />= <br />Date__q I ! < Area Ct) I Employee ID#� <br />Date ! i SPECIAL PERMIT -Approved by <br />Pit/Skmp Soil Character: <br />PE <br />Code <br />AL <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />mit ID# <br />:(117A <br />512Bo 73164 <br />443 39 741211111 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />