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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 / A CALL(209)953-7697 FOR INSPECTIONS /�� EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS _ �(�A ,,n ?c��1CITY/ZIP <br /> �� Lr <br /> CROSS STREET APN ei06 ! o3 '( PARCEL SIZE 7 p' <br /> OWNER NAME -4 �Yl` Imo/cc S L,i4 PHONE <br /> OWNER ADDRESS �ri�i CITY/STATE/ZIP <br /> CONTRACTOR /� y< , ) t "?S�� a'{_ S� PHONEI/ 5�� �/ �p� .5! �y <br /> CONTRACTOR ADDRESS ,An &-k `�S3 CITY/STATE/ZIP j { -,�L Imo! / L•� /rj�} <br /> LICENSE ❑LiC-42 DiiC-36 OTHER NUMBE kL EXPIRATION DATE <br /> WATER TABLE DEPTH: GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> v, <br /> El <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: _ NEW INSTALLATION REPAIR/ADDITION I i ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I I DESTRUCTION <br /> INSTALLATION WILL SERVE: 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 It OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDArION 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 /> f LTER BED WIDTH If ft LENGTH &:llIl 2� I ft DEPTH'r ft <br /> DISTANCE TO NEAREST WELL f 66' ft FOUNDATION 1 i�t ft PROPERTY LINE z S d-' 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 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH O ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE-C 4 . <br /> L] SEEPAGE PITS NUMBER WIDTH ft DEPTH E -- ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 0p, FNte, <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINNANNCCE�ENT <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE G.�,)Aii-C[.'-/y r DATE j`7 —)T— <br /> DEPARTMENT LYSE jONLY <br /> Application Accepted By424Date 0 Area ' C Employee ID# /J <br /> Final Inspection By Date El SPECIAL PERMIT-Approved by <br /> Character of Soil to th ffof Pit/Sump oil Character: <br /> COMMENTS 6�Ulsn <br /> PE SC Received Che Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Bv ash Remitted Service Request# <br /> J s� 10.20 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />