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I It ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JbAQUIN 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 /> Q l� S��c��� 9S�?06 <br /> JOB ADDRESS A � � i) L�.h (�d � CITY/ZIP /' f <br /> CROSS STREET [" o.55uPcj AyQ-. APN 2 O • � Y� PARCEL SIZE O, / d <br /> c ) b <br /> OWNER NAME � PHONE <br /> OWNER ADDRESS sCLCITY/STATE/ZIPSkLk�ok CA 6 <br /> CONTRACTOR PHONE c, <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑EIC-42 ❑nC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: EI NEW INSTALLATION fl REPAIR/ADDITION n ENGINEER DESIGNED(ALTE <br /> RNATIVE <br /> 1.1 REPLACEMENT (I OUT-OF-SERVICE SEPTIC SYSTEM W DESTRUCTION Tafi <br /> INSTALLATION WILL SERVE: ElRESIDENCE El COMMERCIAL 11 OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG 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 D 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 it <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE - <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH <br /> ` q --IS ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY Q ft <br /> El DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH TNTQ NM�C�,�viy ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINET 4 _ ft <br /> 0 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 /> MIN UM 48 HQVR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 <br /> Iq <br /> SIGNED TITLE DATE ' <br /> oo <br /> DEPARTMENT USE ONLY <br /> Application Accepted Date —/ Area 5�4 rj Employee lD# <br /> Final Inspection ByC/_ Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: P Sum Soil Character: <br /> CoInns 00 1;v rerryl, 1 on re cc, enoa�,sh,>� <br /> PE SC Received Cheas Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO ` B Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />