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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 PERMIT CALL 209)9 ,3-7697F,01?INSPECTIONS //,,ExPPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP V ` <br /> CROSS STREET 1 APN 2� .`7 PARCEL SIZE Uy I _ O <br /> OWNER NAME PHONE ^ Q <br /> OWNER ADDRESS 2 q VA CITY/STATE/ZIP V \ CA • l <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑rC-42 11FIC-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: n NEW INSTALLATION I I REPAIR/ADDITION t I ENGINEER DESIGNED/ALTERNATIVE <br /> p <br /> I I REPLACEMENT I_I OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SER\/E: ❑ RESIDENCE ❑ COMMERCIAL 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 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 4k _ ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTHL�/'1 �Ilpft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE® it <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH -4416 �7 P ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLf O ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH � U� Nin,, ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LLII'N'ErH �_��_ �FAI�JEN`T'gT►J "��// ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH M�NT 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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CAL 209 953-Z697 <br /> SIGNED TITLE DATE 1. <br /> 1 <br /> II <br /> i <br /> i <br /> EPARTMENT SE ONLY +? i/ALIERMIT <br /> Application Accepted By4WA _ Date ` Area Employee ID#Final Inspection By Date ❑ S -Approved by <br /> Character of Soil to Depth of 3 Ft: P' Sump Soil Character: <br /> COMMENTS ` <br /> PE SC Received Check# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO 13V ash Remitted Service Request# <br /> Z - o Ao\ S � <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4114/18 <br />