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12..16 <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 PERMIT CALL (209),953-1W91 FOR INSPECTIONS IMXPIKts "I Y tAK I-KUIV UA I t IJJUtI <br />JOB ADDRESSp QS ��J"�� A n CITYIZIP G- O <br />CROSS STREET �F--p> J , APN!� �C�Z O — �7 _ PARCEL SIZE ' <br />OWNER NAME :r.tel/ V 1 r� v \ � I �/ ` ' / PHONE <br />OWNER ADDRESS <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />PHONE <br />CITYISTATE/ZIP <br />LICENSE 11❑C-42 1111C-36 OTHER /' ( NUMBER S _EXPIRATION DA <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # I BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: U NEW INSTALLATION U REPAIR/ADDITION U ENGINEER DESIGNED IALTERNA IVE <br />REPLACEMENT Tc 0 IL ❑ OUT -OF -SERVICE SEPTIC SYSTEM -W DESTRUCTION + L <br />INSTALLATION WILL SERVE: RESIDENCE ElCOMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />a SEPTIC TANK <br />TYPE/MFG j(".-- <br />_ <br />CAPACITY �Gj O L) gal # OF COMPARTMENTS <br />Invoice # Permit ID# <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />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 <br />HOUR ADVANCE NOTICE REQUIRED <br />FOR INSPECTIONS CALL 209 953-7697 <br />SIGNED ' <br />S --PLEASE <br />TITLE DATE 2 —1-:3 -l?f <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS Vjr--A;Z� i &-2W iZPi ��& <br />PE <br />Code <br />SC <br />INFO <br />Received Check#/ Amount Permit/ <br />B Cash m' a Date Service Request # <br />Invoice # Permit ID# <br />O <br />t c7LJ-7 2 131 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />