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,4 <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLEPERMITCALL 209 9533-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS p0 / ��'lClos4ihn 12JCITY/ZIP CO' ) O CA <br /> J J n <br /> G <br /> CROSS STREET cy ! J/ /�dNi 1�fyj,:,� A P N /-)Q, ' f/ PARCEL SIZE <br /> OWNER NAME 04j�� "y Z PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR C. PHONE <br /> CONTRACTOR ADDRESS -sf/ w, 'e- CITY/STATE/ZIP <br /> LICENSE EOL-42 El �C-36 OTHER NUMBER i /G;"'�EXPIRATION DATE 0 D <br /> WATER TABLE DEPTH:­&/� ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTAL LATION i R PAIR/ADDITION OPAP I 1 ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT 1 OUT-OF-SERVICE SEPTIC SYSTEM u DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE I I COMMERCIAL 1-1 OTHER <br /> NUMBER OF LIVING UNITS: ' NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: n <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY {'/U gal #OF COMPARTMENTS e� <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS 1n <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION � ft PROPERTY LINE 1O ' ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP t7 PKG TX PLANT '❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBERS �.+ #OF LINES_ g- LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL _ 7 C ft FOUNDATION /D 1 ft PROPERTY LINE �O ft <br /> ❑ 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 /> iP s <br /> SEEPAGE PITS NUMBER ,gWIDTH ft DEPTH �ZS ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED ��J TITLE DATEC 31 <br /> / �J <br /> q <br /> r N <br /> AIV q rT <br /> .. D PARTMENT SE (INLY <br /> Application Accepted By Date Area Employee ID#� <br /> Final Inspection By (i Date SPECIAL PERMIT-Approved by <br /> Character of Soil to Dept of 3 Ft: P t/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO ash Remitted SeRe u t#-PY <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />