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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 46R 342n <br />IVUN-REFUNDABLE PERMIT CALL (209 953-7697 FOR INSPECTIONS �J EXPIRES 1 YEAR FROM DATE ISSUE <br />JOB ADDRESS .9-9V V A'Z-AY%1 l�li la— • CITY21P_ Ar-rTYYI PO GI S -2 -YO ^ _ <br />CROSS STREET K-CNNE� c r-- APN C� I - Z(% " % PARCEL SIZE z AC -C) - <br />OWNER NAME_ ZVVVI�> gA•..]IG /L�,,-I PHONE 333- Zo&T <br />OWNER ADDRESS P -D, EbX S !lP CRY/STATE/ZIP _)4-CICIMPO <br />CONTRACTOR I.IfF OP'sZo/E,JjyIZONrnE1y-Tr1rL PHONE 3tvcj-C13-7S- c <br />CONTRACTOR ADDRESS "Cy -I W • D✓ -1 r'-- ST- CRY/STATE/ZIP "*t>i Coq <br />LICENSE ODC-42 00C36 OTHER CECT NUMBER ZI TI EXPIRATION DATE 4 -30 -2 -2 - <br />WATER <br />-3O-ZZ <br />WATER TABLE DEPTH: <br />PERC TEST # <br />TYPE OF WORK: <br />C <br />❑ NEW INSTALLATION <br />'u REPLACEMENT <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />BUILDING PERMIT # LAND USE APPLICATION # <br />❑ REPAIR/ADDMON ❑ ENGINEER DESIGNED/ALTERNATIVE <br />OUT -OF -SERVICE SEPTIC SYSTEM C DESTRUCTION <br />FiNSTALLATION WILL <br />SERVE: 11RESIDENCE <br />INFO B <br />❑ COMMERCIAL <br />Service R uest # Invoice # Permit ID# <br />11OTHER <br />NUMBER OF LIVING UNITS: <br />NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ <br />SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />I:] LEACHING CHAMBERS <br />#OF LINES <br />LENGTH OF LINES It <br />DISTANCE To NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />It <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH <br />It LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE It <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft <br />ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft <br />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 />;a <br />O <br />0 <br />y <br />DEPARTMENT USE ONLY <br />Application Accepted By �' /�-!� (/ Date )7, L? Area C Cj Employee ID# F I` <br />Final Inspection By Date ' ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />PE <br />SC Received <br />Check#/ Amount <br />Permit/ <br />Code <br />INFO B <br />i <br />Remitted Date 1 <br />Service R uest # Invoice # Permit ID# <br />I � <br />42-01 <br />4/14118 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />Y <br />