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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT (;ALL (LU.9) UO3-/t.9/ FOR 6NSPECTIONS tXPIRES 'I YEAR FROM LATE ISSUE <br />JOB ADDRESS C f y / CITY/ZIP <br />CROSS STREET APN r� 11 f� — �� / - ��� PARCEL SIZE_ <br />OWNERNAME1��GIY�I'1� '1 PHONE <br />OWNER ADDRESS 51 % IJ�U % S E �y �Q CITY/STATE/ZIP S 1/\ <br />CONTRACTOR o ✓ �GJ C�1 1 PHONE <br />CONTRACTOR ADDRESS CITY/STATEIZIP <br />LICENSE 110C-42 110C-36 OTHER NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT #4r- <br />21 -jV0-S LAND USE APPLICATION # <br />TYPE OF WORK: L NEW INSTALLATION REPAIR/ADDITION ��fiM L ENGINEER DESIGNED /ALTERNATIVE <br />F <br />SEPTIC TANK <br />TYPE/MFG <br />Received <br />B <br />heck#/ Amount Date <br />as Remitted <br />Permit/ <br />Service Request # <br />CAPACITY <br />7 <br />oZ <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF <br />DISTANCE TO NEAREST: WELL <br />ft <br />FOUNDATION <br />ft PRO"UNTr <br />ft <br />❑ LIFT STATIONSIZE <br />TYPE OF PUMP <br />PKG TX PLANT <br />❑ <br />SAND OIL SEPIMIA <br />SYSTEM) <br />-❑ <br />r� <br />❑ <br />❑ __LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES <br />ft <br />�S NCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />!F-'O'—OWIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />�OUNDED <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft -" PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />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 />Character of Soil to Depth of 3 Ft: N sump sou cnaracter: <br />COMMENTS �OY1 �' 1? <br />T ef4l,. Avf �.A �>r.k <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />heck#/ Amount Date <br />as Remitted <br />Permit/ <br />Service Request # <br />Inv # <br />7 <br />oZ <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />