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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-REFUNDABE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIR <br /> E <br /> S 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSled CITY/ZIP <br /> CROSS STREET // APN" O �'D b G - " PARCEL SIZE ifi y <br /> OWNER NAME I PHONE <br /> OWNER ADDRESS fl CITY/STATE/ZIP W14Jh7uC y ftuc--`/, /VIL <br /> CONTRACTOR ��, ) /� PHONE �d� g�/ �dl ` <br /> CONTRACTOR ADDRESS /j�2 vQ CITY/STATE/ZIP �/ �� �s <br /> LICENSE ❑I iC-42 1111C-36 OTHER NUMBER �i2--?EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION 1_1 ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM l DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG ` Z-- CAPACITY J // 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 /> F] LEACH LINES I I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> G 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 /> MINIM 48 HOUR ADVANCa NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-76997 G <br /> SIGNED TITLE G�d DATE <br /> R <br /> EP <br /> d <br /> 19E ARTMENT SE N Y <br /> Application Accepted By Date 'AlfArea Employee ID#� <br /> Final Inspection By Date ❑ SPE IAL PERMIT-Approved by <br /> Character of Soil to DeptKOt: P Sump Soil Character: <br /> COMMENTS LfT__ <br /> PE SC -ReceivedCheck Amount Permit/ <br /> Code INFO B mash Remitted Date Service Request# Invoice# Permit ID# <br /> Q0 I0; L402 JAgo2 , 7 l9MV3 <br /> -- - <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />