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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PER//MIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS bAft CITY/ZIP <br /> CROSS STREET .{- APN I4I,- V Z PARCEL SIZE 0 p <br /> 0 <br /> OWNER NAME �./ L)� �C/ N PHONE rrl <br /> OWNER ADDRESS �L'S VL CITY/STATE/ZIP <br /> /1 <br /> CONTRACTOR gpleAIa k , Pin% :e /SQ�Qf` PHONE <br /> CONTRACTOR ADDRESS /�y �/_`�r' �� S <br /> -+ CITY/STATE/ZIP /!��/� G�. S�Jy`r <br /> LICENSE 11(!C-42 01 C-36 OTHER /7 NUMBER /IJ 7 Tf EXPIRATION DATE J <br /> WATER TABLE DEPTH:[iC/ %y ��"�� ft- F GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE 11 COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> L3 SEPTIC TANK TYPE/MFG (1V�7 CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG 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 1i LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Id FILTER BED WIDTH ft LENGTH 3 2 ft DEPTH _ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION SD ft PROPERTY LINE LS 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 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 /> MINIM M 4 OUR ADVANCE NOTICE RE I D FOR INSPECTIONS// - PLEA E ALL (209)953-7697 <br /> SIGNED TITLE 60�q DATE <br /> g J A <br /> al! <br /> q -TM Ell <br /> PARTMENT SE NLY G� <br /> Application Accept4Dpth <br /> Date l Area ` Employee ID# o <br /> Final Inspection By �/ Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to of 3 Ft: Pit/S mp Soil Character: <br /> COMMENTS !`15�f= ff, ,, -CJ/1 MYI-rd G _ /[/ l�L LS .6&Eeg .e'& <br /> PE SC Received hec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO BA ash Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />