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Y <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-REFUNDABLE PERMIT!` CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �_o -7 d Llt�� �x ✓� CITY/ZIP t��</��iri Ca✓t✓� i Gy� •Sd3 1 <br /> .n 'J M <br /> CROSS STREET ��1G� ���Y1 F APN 1 PARCEL SIZE y • �� <br /> M qC/ G c <br /> OWNERNAME Vt �fI /�AC` C��(��� 11( 6�t� -4 �'SR h�fic I`{r-L PHONE L ZJ "L4 D7� <br /> OWNER ADDRESS /X3 r.c�/ CITY/STATE/ZIP �} <br /> CONTRACTOR I'M r ' I ��C}� Ak� Z�f�r! �Y� S�`� PHONE 1 <br /> CONTRACTOR ADDRESS PO 1 X �� CITY/STATE/ZIP / I 4-w,-&4- <br /> LICENSE ❑' C-42 Eli,C-36 OTHER NUMBER EXPIRATION DATE_ 2::Oan <br /> WATER TABLE DEPTH:?� 7n ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT## LAND USE APPLICATION## <br /> TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION <br /> 7INSTALLATION WILL SERVE: L? RESIDENCE ❑ COMMERCIAL ElOTHER <br /> NUMBER OF LIVING UNITS: I 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 I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> FILTER BED WIDTH Inn ft LENGTH L4 ft DEPTH (g'I ft <br /> DISTANCE TO NEAREST WELL j 'J:51 ft FOUNDATION In r ft PROPERTY LINE IS r 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 48 HOUR ALWANf.LN0T10E REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE1"c e,{5 DATE ��5�.} <br /> SAN O Q IN O N <br /> L <br /> • <br /> EPA RTMENTUS ONLY <br /> Application Accepted Date Z-� Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS :nf�:", (ZIVP!r MLAIC!YJ <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Qash Remi ed Service Request# <br /> o u " 0 5 � <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />