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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 /> NON-REFUNDABLE <br /> `PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I i w � �+� 1 t/^ y JO CITY/ZIP :t Ec4 V <br /> CROSS STREET �I c�• APN -_��j 3� O(r� PARCEL SIZE Y <br /> v <br /> _ c <br /> / c m <br /> OWNER NAME ��:�� 1� PHONE � 3l S <br /> OWNER ADDRESS �l k,/C/� t1 ✓17 I''���r �tl� CITY/STATE/ZIP ,I �<<%y 1 c Vt 5 �� <br /> c <br /> CONTRACTOR (.e,u' PHONE <br /> CONTRACTOR ADDRESS � e ^^// `9D_�) I, h V', y� CITY/STATE/ZIP <br /> LICENSE Ili C-42 ❑f;C-36 OTHER AT NUMBER 5'--;' EXPIRATION DATE <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/ADDITION I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION <br /> INSTALLATION WILL SERVE: LRESIDENCE ❑ COMMERCIAL 11OTHER <br /> IA\ <br /> NUMBER OF LIVING UNITS: ,n NUMBER OF BEDROOMS: cat NUMBER OF EMPLOYEES: <br /> Q.-'SEPTIC TANK TYPE/MFG CAPACITY 0 O gal #OF COMPARTMENTS <br /> (3 GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL (r]Q` ft FOUNDATION (',l!� ft PROPERTY LINE .)" / ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES 1001 ft <br /> DISTANCE TO NEAREST WELL, ft FOUNDATION ( ft PROPERTY LINE C-5' 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 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (2091953-7697 <br /> SIGNED 6 TITLE DATE I 1 <br /> WENT- <br /> 4N,10A QL IN <br /> hAVIRObMENTAL <br /> DEPARTMENT LVSE ONLY <br /> Application Accepted By Date— (/ < Area / Employee ID# <br /> Final Inspection By a�f N Date ❑ SPE IAL PERMIT-Approved by <br /> Character of Soil to Dep f 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS 2 (RI — <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Request# <br /> off 10 qf <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />