Laserfiche WebLink
ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-KEFUNDABLE PERMIT (:ALL <br />JOB ADDRESS <br />CROSS STREET N e r\ r v <br />OWNER NAM <br />F�bX�L�'1�Y+I:LGF97�+jI[d.65 <br />L12lit* d=M!IJ -9161J_'%01111F1411A <br />CITYIZIP �7IM+i►.L�.�'�riSl� <br />rS -OaaQ PARCELSIZE�. <br />A_ r .t- <br />OWNER ADDRESS CITY/STATE/ZIP <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />LICENSE 110C-42 110C-36 OTHER <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER EXPIRATION DA <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />❑ REPLACEMENT IJ OUT -OF -SERVICE SEPTIC SYSTEM ,k DESTRUCTION TC1 i1 <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft 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 />❑ LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft 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 />MINIMUM Q <br />HO R ARYANCE NOTICE RE <br />U/RED FOR INSPECTIONS - PLEASE CALL 209 953-,71697 <br />SIGNED <br />TITLE 0 w v� <br />� �' DATE <br />DEPARTMENT SE ONLY <br />Application Accepted By r- L Date o� q �l ? Area /% Employee ID# 146 <br />Final Inspection By Date ?1Zi1, ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS Deme 6-F id on-ren.,�Ir "T,Fv <br />PE Sc <br />Code INFO <br />42-01 <br />Received <br />as <br />Amount Date Permit/ Invoice # Permit ID# <br />Remitted Service Re uest # <br />-7s <br />�a 1 0-7-5- <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />