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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 <br /> PERMIT / CALL 209 953-7697 FOR INSPECTIONS ExPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> CITY/ZIPU:y <br /> CROSS STREET . �< Pt r.7 APNy l <br /> � PARCEL SIZE S <br /> OWNER NAME /�/A'1 J.n� `/C� (I-Z, G PHONE <br /> X7 <br /> M <br /> OWNER ADDRESS C (-./�.�y. d?JC;�� -�� CITY/STATE/ZIP *�-O� <br /> CONTRACTOR /� IT I �. � -IJ�/ PHONE � <br /> a /� �- /���'/ <br /> CONTRACTOR ADDRESS / �1'�� ~ CITY/STATE/ZIP <br /> LICENSE ❑LIC 42 ❑L.IC-36 OTHER ` NUMBERJ EXPIRATION DATE / //0/ 2- <br /> WATER <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: i: NEW INSTALLATION 1.7 REPAIR/ADDITION I_! ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT tGN � L)Nc* 1 OUT-OF-SERVICE SEPTIC SYSTEM IP DESTRUCTION T4141C <br /> INSTALLATION WILL SERVE: ,� RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: -� NUMBER OF EMPLOYEES: <br /> la SEPTIC TANK TYPE/MFG /' ` �•�-�L�r CAPACITY Z J= gal #OF COMPARTMENTS L <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> r <br /> DISTANCE TO NEAREST: WELL Z�" ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT, ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> M LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES S J ft <br /> DISTANCE TO NEAREST WELL /0,i it FOUNDATION L:' ft PROPERTY LINEy 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 /> 2 SEEPAGE PITS NUMBER �G, WIDTH j' ft DEPTH Z S ft <br /> DISTANCE To NEAREST WELL /)V ft FOUNDATION �'V 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 /> MINIMUIV1448 <br /> /HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS --PLEASE CALL 209 953-7697 <br /> SIGNED TITLE L' �Y DATE <br /> A <br /> N <br /> TM <br /> DEPARTMENT IJSE ONLY f <br /> Application Accepted By —� Date / Zv l 0 Area _a Employee ID#D_ <br /> Final Inspection By ' Date (� 3 ZO ❑ SPECIAL PERMIT -Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS X) tln S cfewl or, ex, •}I),?,-, lot U,+e - S . -fe <br /> PE SC Received Check#I Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Remitted Servic Request# <br /> LIR 10 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />