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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMITC_ALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> _ <br /> JOB ADDRESS �-� CITYIZIP,o�,_12�, <br /> CROSS STREET s, APN y�_040 -1 5- PARCEL SIZE <br /> OWNERNAME — Q / PHONE 'GO/�' <br /> OWNER ADDRESS/J CITY/STATE21P ` 8 <br /> CONTRACTOR /r/rJ ��[�r .N�.�1 Lf•�1 G PHONE �''/ fLZ <br /> CONTRACTOR ADDRESS �(5,�� J� 4+' 4' 7­6- //�� JJyy� CITY/STATE/LIP S i--/'"/j)w/ rte+ ��✓�i <br /> LICENSE XC-42 -IC-36 OTHER A NUMBER�T�i,��/�--77 EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> L PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: 1 NEW INSTALLATION REPAIR/ADDITION rl ENGINEER DESIGNED/ALTERNATIVE <br /> J REPLACEMENT /7 DESTRUCTION <br /> INSTALLATION WILL SERVE: F RESIDENCE COMMERCIAL I- OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES f_I LEACHING CHAMBERS #OF LINES LENGTH OF LINES > ft <br /> J i <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE T It <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL It FOUNDATION ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE141, ft <br /> SEEPAGE PITS NUMBER WIDTH ft DEPTH Z — ' ft <br /> DISTANCE TO NEAREST WELL /�>>�ft FOUNDATION �/�l- ft PROPERTY LINE <br /> 1 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 /> MINNI/IMUM 24 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE rFi O DATE <br /> 0 <br /> O <br /> • <br /> II <br /> v <br /> l <br /> r I L <br /> i I <br /> fA Jl - <br /> t 1 EPCL <br /> S <br /> NL <br /> PARTMENT U E LY / <br /> Application Aces p Date Area Employee ID# <br /> Final Inspection y�� - - Date - El SPECIAL PERMIT-Approved by <br /> Character of Soil to Dp th of 3 Ft: PiUSump Soil Character: <br /> COMMENTSjc <br /> PE SC Received Choc Amount Date Porml Invoice# Permit ID# <br /> Cod INFO B Cash emitted Service Request# <br />