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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOADUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1869 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL -7697 FOR INSPECTIONS EXPIRES 1 �YEAR <br />}FROM DATE ISSUE[ <br />JOS ADDRESS 4.4-137 G T <br />,__.,.. .1✓.))_CITY/m1,- <br />CROs STREET APN7$+_..............._._. _� PARCEL SIZE <br />, <br />OWNER NAME �'1 <br />_ PHONE <br />OWNER ADDRESS CITY/STATE21P �( PDA), <br />,AA5 '3� <br />y (7J�sCONTRACTOR 4 "1 PHONE . <br />CONTRACTOR ADDRESS Fin 1-G,,� ____.._._...-.._._--CITY/STATE21P C✓ � <br />LICENSE [1:.C-42 �F]:::,C-38 OTHER„ 4-- NUMBER-7I� J EXPIRATION DATE <br />WATER TABLE DEPTH: It GEOORAPHICALINFORMATiON: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ..: NEW INSTALLATION 7- HEPAIRIADOITION ENGINEER UESIGNED 1ALTERNAT E <br />REPLACEMENT .., OUT -OF -SERVICE SEPTIC SYSTEM 4 DESTRUCTION <br />INSTALLATION WILL SERVE: JIP RESIDENCE I COMMERCIAL ❑ OTHER-_ <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />iS SEPTIC TANK TYPEIMFG CAPACITY G O J gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG CAPACITY __,_- gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL �� _ It FOUNDATION it PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT O 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 It LENGTH <br />__._ <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION <br />_, It PROPERTY LINE h <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH It <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION <br />ft PROPERTY LINE ft <br />Cl SUMPS <br />WIDTH __ It LENGTH <br />It DEPTH It <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION <br />----ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH It LENGTH <br />it DEPTH ft <br />DISTANCE TO NEAREST WELL <br />it FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />it DEPTH _ ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />It 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 241HOUR <br />ADVANCE NOTICE REQUIRED <br />FOR INSP-AC+ECTIONS- PLEASE CALL 209 933-769 <br />SIGNED <br />TITLE zn&j <br />/7 <br />d r DATE .S';1 ! <br />0EPAPTNEN" S ' ONLY <br />Application Accepted By .�,. ,.,.. Date Area ��TT Employee ID# <br />Final Inspection By Date_ _................_ — = SPECIAL PERMIT - Approved by <br />Character of Soil epth of 3 F : it/Sump Soli Character: <br />COMMENTS <br />PE SC Received Chee AmountParmlU Invoice # Permit ID# <br />Code INFO B ash Remitted Service Request # <br />ti Date ,5wl,-(7 M00'77 3jtb <br />42-01 <br />4/24112 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />a <br />