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IL I 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)953-7697 FOR INSPECTIONS .-� EXPIRES 1 YEAR FROM DATE ISSUED <br /> LA <br /> JOB ADDRESS CITY/ZIP <br /> l <br /> PARCEL SIZE p <br /> CROSS STREET U✓ APN a <br /> OWNER NAME L PHONE Cn <br /> OWNER ADDRESS / CITY/STATE/ZIP <br /> `/ <br /> CONTRACTOR / �r C PHONE �Q� — �J`f ✓D� / [� <br /> CONTRACTOR ADDRESS 67),7I D601, ��' CITY/STATEIZIP <br /> LICENSE ❑ iC-42 ❑LIC-36 OTHER NUMBER O EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: CI NEW INSTALLATION El REPAIR/ADDITION ❑ ENGINEER DESI ED/ALTERNA IVE <br /> 1.1 REPLACEMENT n OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: 1_ / NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG �lfl�IC'!e CAPACITY O gal #OF COMPARTMENTS <br /> ///❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL �V / ft FOUNDATION S ft PROPERTY LINE 30 ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES I_I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 LINE ft <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 LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLhCATION 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -- PLEASE CALL (209)953-7697 <br /> SIGNED TITLE DATE <br /> y <br /> y <br /> F R Vi <br /> E 1 <br /> M <br /> D P A R TM E N TXJ S E10NLY <br /> Application Accepted B n Date . Area Employee ID# <br /> Final Inspection By Date tal ❑ SPE IAL PERMIT-Approved by <br /> Character of Soil to Dielpth of 3 Ft: Pit/S mp oil Character: <br /> COMMENTS <br /> 6C r-Mal s iS l —S d,� -ti rv� <br /> S �G NaB n IXA aod CnaKad & els +j <br /> PE St Received ec Amount Permit/ <br /> Code INFO B Cash Remitted Date Service Re uest# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />