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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 CALL(209)_9.53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSlzzr CITY/ZIP �'�` <br /> CROSS STREET (/�,k1� �j APN b�� V _PARCEL SIZE <br /> / O <br /> OWNER NAMEAMI—LI/ /4-li4 ' PHONE O <br /> OWNER ADDRESS 10 CITY/STATE/ZIP 2,1 <br /> CONTRACTOR-� — /� ! f'X/�- _ PHONE__q� 7�'Y <br /> CONTRACTOR ADDRESS �Q�26�a� CITY/STATE/ZIP <br /> LICENSE LII-JC-42 ❑1IC-36 OTHER /11 NUMBER i0 EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# r V U LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION 0 RdPAIR/ADDITION EI ENGINEER DESIGNED/ALTERNATIVE <br /> U REPLACEMENT U OUT-OF-SERVICE SEPTIC SYSTEM D DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> LL NUMBER OF LIVING UNITS: �_ NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG 10010.� 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 l ft <br /> DISTANCE TO NEAREST WELLy/1//H _ ft FOUNDATION /2"4 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 FQUNDATION ft PROPERTY LINE ft <br /> ple- SEEPAGE PITS NUMBER WIDTH 7�P ft DEPTH O� ft <br /> DISTANCE TO NEAREST WELL=lA ft FOUNDATION f P "4 _ ft PROPERTY LINE ��' ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THEE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIAWM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 <br /> SIGNED TITLE l, � DATE <br /> IV <br /> JUN I <br /> EiQ, /N <br /> Iwk'1/VV- <br /> N <br /> D ARTMENT USE ONLY <br /> Application Accepted Byate 70 Area Employee ID# <br /> Final Inspection By Date ?� L_I SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: _ Pit/Sump Soil Character: <br /> COMMENTS __���,��L�- l �j <br /> PE SC Received r-TEe--c*DP Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted i _ Service Re(lUest# <br /> I �M l l'1 i <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />