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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT ` CALL 209 953-7697FOR INSPECTIONS / EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /� _CITY/ZIP ` S G of to/` C N s 3 2-0CROSS STREET <br /> „ 'Y� T 1�Q/ L�l d r— _ APN _2 I - O PARCEL SIZE 1 4-G J p I_r d� <br /> IJ�J f O <br /> OWNER NAME rrW !j`�l F..^`J� O C/5/� PHONE 9 "k� P' O <br /> OWNER ADDRESS �/J SJ '� /1` / a �l �KON _ CITY/STATE/ZIP J SG4; <br /> CONTRACTOR SCJl_ PHONE <br /> CONTRACTOR ADDRESS _ —CITY/STATE/ZIP <br /> LICENSE Df-iC-42 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> I PERC TEST # _- _ BUILDING PERMIT# LAND USE APPLICATION <br /> TYPE OF WORK: NEW INSTALLATION I REPAIR/ADDITION Ll ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT l 1 OUT-OF-SERVICE SEPTIC SYSTEM Cl DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE lJ COMMERCIAL ❑ OTHER <br /> 111111 NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: _ _ \ NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG PL CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG _ CAP CITY _. gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP _ _ O PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBERS_ #OF LINES LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL lUV ft FOUNDATION It PROPERT'1114 NE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LIN ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH RE[��/���_ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH Z ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROP_ gWAQJI{fd Cam— ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH HE ENVIROME r <br /> -'-- y ft <br /> ,9 <br /> EN <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE LPARTA4r-- ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It <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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE J 4;1-' DATE /-2-- <br /> I <br /> 6� <br /> e� <br /> 0 41 <br /> 1 0 <br /> v 1-4 <br /> of <br /> I <br /> D TMENT USE ONLY � ��yp _ <br /> Application Accepted By Date Area � -' Employee ID# <br /> Final Inspection B c°-- Date a 3� ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to epth o 3 Ft: it/Sump Soil Character: <br /> COMMENTS n (mac <br /> PE ScRec Ived he k Amount P rmit/ <br /> Code INFO By Cash Remitted Date Service Request# Invoice# Permit ID# <br /> 4zlo 115 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />