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t <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 [ MID <br /> (2009 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 7 li 1� ID �� Cha. CITY/ZIP <br /> j <br /> CROSS STREET 1 APN,�O, e3q— 2-bu �� PARCEL SIZE qI p <br /> 0 <br /> A <br /> OWNER NAME PHONE y <br /> OWNER ADDRESS � G � ►/'^ p CITY/STATE/ZIP <br /> T <br /> CONTRACTOR e-Sr S <br /> PHONE <br /> CONTRACTOR ADDRESS Kar, °�� S-� CITY/STATE/ZIP Lo& ' CA q5'40 <br /> '7 � <br /> LICENSE ❑A1C-42 ❑L µA C-36 OTHER ' \ NUMBER X551 5� EXPIRATION DATE /l-/��2 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: COdinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# d LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION I R PAIR/ADDITION _. ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT r OUT-OF-SERVICE SEPTIC SYSTEM - DESTRUCTION <br /> INSTALLATION WILL SERVE: )Lq,RESIDENCE I I COMMERCIAL OTHER <br /> 2 <br /> NUMBER OF LIVING UNITS: p NUMBER OF BEDROOMS: ✓i�7 NUMBER OF EMPLOYEES: <br /> L <br /> �. SEPTIC TANK TYPE/MFG ` CAPACITY \ 00 gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG i 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 /> It LEACH LINES ❑ LEACHING CHAMBERS �(�� I tYOC�YcJ #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION I I l' l ft PROPERTY LINE `t 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 3 WIDTH �W )) ft DEPTH ft <br /> DISTANCE TO NEAREST WELL 1'j0 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 TITLE_ DATE <br /> `D PARTMENT SE afNLY <br /> Application AccepteByI tt Date_ajArea Employee ID#� <br /> Final Inspection By Date M4-6--, ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to epth of 3 Ft: Pit/Sump Soil Character: Q) - <br /> COMMENTS —4� <br /> PE SC Received eck#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By emitted Service Request# <br /> 70 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />