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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 />IVUN-KEFUNDABLE PERMIT CALL (ZUY) W)J-111j.9! FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS 12-1 `v ' •` " FC�r� I� 4� c CITY/ZIP <br />CROSS STREET F�SNi �� v ` APN TT �(/ PARCEL SIZE <br />OWNER NAME U ((PHONE <br />OWNER ADDRESS D� CITY/STATE/ZIP %%" a <br />CONTRACTOR T L�s�( r!- 13k � iNf- PHONE LCJ�� 3-Yi '7 3c-1 1 <br />CONTRACTOR ADDRESS j;�? V1/a-L CITY/STATE/ZIP LL i) I CA- <br />LICENSE I C-42 I C-36 OTHER G'1 NNUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />IJ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION I REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM x DESTRUCTION t»mow <br />INSTALLATION WILL SERVE: I I RESIDENCE COMMERCIAL OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />GREASETRAP TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />CAPACITY gal # OF COMPARTMENTS _ <br />CAPACITY 1 �c V gal # OF COMPARTMENTS <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />Check#01 <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PR Yt� NE ft <br />❑ FILTER BE <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />mit ID# <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft LINE VIA[ft <br />❑I =' <br />WIDTH ft LENGTH <br />ft DE'- ft <br />Service Request # <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LIN ft <br />❑ <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND <br />E A E WITH SAN JOAQUIN COUNTS CES, <br />THE WORK WILL BE� <br />DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINIMUM 24 <br />HOUR 4MCE NOTICE REQUIRED <br />FOR INSPECTIONS - PLEASE CALL 209 953-76«.97 <br />SIGNED <br />TITLE L -Z VVV:�T'C��ti2— }� 6N DATE 1 — :.L' -� <br />�&/� S . <br />EPARTMENTIUS O LY <br />Application Accepted By Date -5/1 Area Q Employee ID#_���2YVC� <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 />SC <br />Received <br />Check#01 <br />Amount <br />Date <br />Permit/ <br />I I <br />mit ID# <br />Code <br />INFO <br />B <br />— Cdsh' <br />Remitted <br />Service Request # <br />e <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />