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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 I I CALL 2 'j2 It- <br /> ,1953-7697 FOR INSPECTIONS E/XPIR�EESA1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> V CITY/ZIP !�C/l <br /> CROSS STREET /✓�C' / 12 r// / Q <br /> AP N PARCEL SIZE <br /> OWNER NAME PHONE�( <br /> OWNER ADDRESS J 6 Y/STATE/ZIP / ��J V <br /> / / <br /> CONTRACTOR�o///J�/ C`��� L��` l'U PHONE /'� �'�` /�( <br /> CONTRACTOR ADDRESS �(/ C�7�� >✓ CITY/STATE/ZIP ��f/ <br /> LICENSE ❑ C-42 ❑l iC-36 OTHER r-z NUMBER J EXPIRATION DATE <br /> WATER TABLE DEPTH: I20 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION I REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM 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 #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 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 4ffHQUR1ADVAJVCQlii6T10E REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7s97 <br /> (, <br /> SIGNED TITLE 61�G -� DATE12-10LI-Z <br /> T <br /> r � f <br /> ' v ry <br /> rpJAL <br /> AiT <br /> E P A R T M E&T LISE i N L Y <br /> Application Accepted By Date 12LO I Area mployee ID# <br /> Final Inspection By fl1J �; ���Q lL Date 1 ❑ SP CIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS IIA_v_ VC) tb 'vl)A= - I?Uj�is' <br /> P"\ - <br /> PE SC Received Check#/ Amount Permit/ <br /> CCoTde' INFO B Cash emitted Date Service Re uest# Invoice# Permit ID# <br /> v v <br /> 42-01IQ� �j ge71� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 r ✓ U <br />