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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 /> L <br /> NON-REFUNDABLE PERMIT / CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z h� �� /� e h C < < of CITY/ZIPeC/0,01 <br /> CROSS STREET A14- ! XL APN zz j-OT 6 o-1, PARCEL SIZE . 1' <br /> d <br /> 4 <br /> �, v` PHONE p /� <br /> OWNER NAME L /`� /� I�+ O �s / �/ - �'- <br /> OWNER ADDRESS 6/ 2 '-�/^GZ L✓ / C A N C Y CITYISTATE/ZIP d s�W A <br /> CONTRACTOR `/a S YY SLS K/ C/� PHONE "q -� <br /> CONTRACTOR ADDRESS �O l D le /1 Q i / �� CITY/STATE/ZIP Je""n <br /> LICENSE l I'C42 ECIC-36 OTHER NUMBER Pna EXPIRATION DATE <br /> WATER TABLE DEPTH: ft ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT it LAND USE APPLICATION# <br /> TYPE OF WORK: L NEW INSTALLATION ❑ PAIR/ADDITION CI ENGINEER DESIGNED/ALTERNATIVE <br /> LI REPLACEMENT f I OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION _ <br /> INSTALLATION WILL SERVE: VeRESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: /�j NUMBER OF EMPLOYEES: <br /> f_ 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 F1 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> �j J // <br /> FILTER BED WIDTH �7 ft LENGTH <br /> � ft DEPTH 2,�if_ <br /> G�Z ft <br /> DISTANCE TO NEAREST WELL V f ft FOUNDATION ft PROPERTY LINE 4�' 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 H UR DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE Ad -e r DATE <br /> SAN JAUI C <br /> ENVIRONMENTA- <br /> PARTMENTJJSE ONLY <br /> Application Accepted UY _ Date Area _ Employee ID# <br /> Final Inspection By _ _ Date ❑ SPE IAL ERMIT-Approved by <br /> Character of Soil�to;Depth of 3 t: — Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B Cas Remitt Date Service Request# Invoice FI Permit ID# <br /> t <br /> 42-01 "��- ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4114/16 <br />