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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS Cyr ci: CrTY/ZIP <br /> CROSS STREET I �1� APN �j[� �[ -j:�2 PARCEL SIZE <br /> OWNER NAME��/�GC/y n /,/� L/C✓L/ p <br /> PHONE <br /> OWNER ADDRESS CITY/STATEIZIP <br /> CONTRACTOR1: <br /> PHONE <br /> CONTRACTOR ADDRESS y'i 314 CITY/STATFJZIP l.c�• <br /> LICENSE VC-42 QC-36 OTHER NUMBER VS�/G ."� EXplRATION DATE /'Z <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/AODITION D ENGINEER DESIGNED(ALTERNATIVE <br /> D REPLACEMENT F OUT-OF-SERVICE SEPTIC SYSTEM 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER_ <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> Q SEPTIC TANK TYPE/MFG X/L CAPACITY ?G gal #OFCOMPARTMENTS T <br /> Q GREASETRAP TYPE/MFG CAPACITY 'J gal #OFCOMPARTMENTS <br /> DISTANCE TO NEAREST: WELL7i R FOUNDATION 7G ft PROPERTY LINE ft <br /> 13LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> EJ LEACH LINES 0 LEACHING CHAMBERS 0-,�2 1 #OF LINES ,7 LENGTH OF LINES SG' ft <br /> DISTANCE TO NEAREST WELL AGO It FOUNDATION SCS ft PROPERTY LINE "C- ft <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 ft FOUNDATION ft PROPERTY UNE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSALPONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> .❑' SEEPAGE PITS NUMBER .r WIDTH `a It DEPTH .�)S , It <br /> DISTANCE TO NEAREST WELL 152:' 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 � <br /> TITLE DATE i <br /> C p <br /> — — I <br /> flu I <br /> _-.r•I <br /> i1 <br /> Lt L - <br /> I <br /> _ ,iDEPARrMENT, U SE ONLY <br /> Application Accepted ft. Date ' Area Employee ID# <br /> Final Inspection By ,''i .r' Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to DeO of 3 Ft: PiUSump Soil Character: <br /> COMMENTS <br /> PE <br /> I <br /> PE SC Received C r1w Amount Date PermiU invoice# PermitlDt <br /> Code INFO as '3 Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 9121/10 <br />