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y, ' ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS m^EXP ES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS )20 <br /> l JCIIjTY/ZII�P ow/ � l <br /> CROSS STREET {Ilk ' APN -� 16✓ V 3 PARCEL SIZE y <br /> OWNER NAME �`�"1�— V / PHONE q 64,�2 5699 J <br /> OWNERADDRESS CITY/STATE/ZIP cS L 9S3Z-� <br /> CONTRACTOR 7C i-i I"1 PHONE / <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑0C-42 ❑LIC-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: D NEW INSTALLATION CI REPAIR/ADDITION U ENGINEER DESI NED/ALTERilATIVY <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM X DESTRUCTIO <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 #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP Q PKG TX PLANT U SAND CIL 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 ft <br /> CJ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Q 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 /> C SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY RTIFY HAT I HAVE PREPARE THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> ATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> IN/ 48 OUR DANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL 209 953;769 <br /> SIGNED J TITLE Yti/ — DATE <br /> Ift <br /> 0 <br /> H o MAmN <br /> _ <br /> 4r- <br /> EPA R TSEONLY <br /> Application Accepted By Date Area _ Employee ID# <br /> Final Inspection By Date—i 1 ❑ SPEC AL PERMIT-Approved by <br /> Character of Soil to De6th of. F . Pit/Sump Soil Character: <br /> COMMENTS 4nm <br /> 0 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Request# <br /> 43V <br /> to to s Roo 1 a 5(o <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br /> 2A- <br /> C�32� <br />