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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 209 953-7697 FOR INSPECTIONS {� EXPIRES ) �1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP y�t�,-w¢►�H S+nc IG Y1 95-d ,7 <br /> a <br /> t y <br /> CROSS STREETL�1 ^�APN 1 y 3 R oa PA,,RyC�ELISIZE <br /> OWNER NAME �� �L PHONE (90CA I 9q O <br /> OWNER ADDRESS (/� CITY/STATE/ZIP <br /> CONTRACTOR -,J►7('1- PHONE <br /> CONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE ❑LIC-42 ❑I..IC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: C NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> D REPLACEMENT t1 OUT-OF-SERVICE SEPTIC SYSTEM W DESTRUCTION tci VI k <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: 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 ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 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 /> l 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 It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERF THAT I HAVE RE ARED 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 /> MIN UM 48 H CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7W7 <br /> SIGNED TITLE OL>-/VCP- DATE _ o5' <br /> T <br /> alo <br /> Ann <br /> like xy <br /> 0 <br /> IV/ <br /> O ON <br /> DEPARTMENT USE ONLY Dep <br /> Application Accepted By L � Date S .7) „z,0 Area o2 Employee ID# MINT <br /> Final Inspection By 1. Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Charac er: <br /> COMMENTS Ome 4-ahk ries)-mVled4Y1 6,' /7':5 eco Y'd tz k ail rc"5�65 pwee/ ql?/ Anklof <br /> 7l2/Yc/ ttnk I's be)"q pe1riwi,y- <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Request# <br /> Naa 1 075- iso DU 2-ll <br /> 42-01eR* dDT3_T <br /> ` 55 �� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />