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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-REFUNDAW PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS S t""� ��� CITY/ZIP <br /> jCROSS STREET � APN3 7PARCEL�SIZE <br /> l <br /> OWNER NAME D _ ik w� PHONE Zza <br /> OWNER ADDRESS 2-*Yef, !�7-.6 tp /�2 % CITY/STATE/ZIP <br /> CONTRACTOR 0ove MCI, PHONE 1'7.1 <br /> �6 <br /> v <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑0C-42 ❑nC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> n PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Li ENGINEER DESIGNED/ALTERNATIVE <br /> U REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM 1.7 DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL 11 OTHER <br /> J <br /> p� NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ` NUMBER OFIMPLOYEES: R/ <br /> yl -SEPTIC TANK TYPE/MFG � L CAPACITY l FJU 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 #Or-LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> '/ t <br /> FILTER BED WIDTH ft LENGTki ft DEPTH 42 ft <br /> DISTANCE TO NEAREST WELL�4- 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED /N TITLE Dom'QO DATE 16 2/- <br /> d�Q <br /> _ 7 <br /> U <br /> M � <br /> C <br /> EPARTMENT UIS E NLY T <br /> Application Acceptedy Date Area /0 Cl Employee ID# <br /> Final Inspection By Date 7- ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of Ft: _ Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Chec AmountPermit! <br /> Code INFO By h Remitted Date Service Re uest# Invoice# Permit 1D# <br /> as <br /> 1 I 1 I I bib -If 5-3 310 S 8 '-b 05 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />