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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 f� 6 // <br /> CROSSSTREET APN 0 P J I�v �/ PARCEL SIZE r6 d rN* <br /> � <br /> OWNER NAME 1 9 D PHONE /' ; <br /> OWNER ADDRESS S5 SS t,,f•" -7/ CITY/STATE/ZIP L-It).C^(?�04 qgR J <br /> CONTRACTOR PHONE �� J /�/ <br /> CONTRACTOR ADDRESS ������ 1✓/J 1--4 <br /> CITY/STATE/ZIP .)fiY��y!! CJ 95 1,5- _ <br /> LICENSE ❑DC-42 ❑CIC-36 OTHER NUMBER /0 O EXPIRATIONDATE�Z. <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 �! , REPAIR/ADDITION LI ENGINEER DESIGNED/ALTERNATIVE <br /> 0 REPLACEMENT /L1 OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <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 G SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> law <br /> ALEACH LINES L LEACHING CHAMBERS - #OF LINES_� LENGTH OF LINES 7y� ft <br /> DISTANCE TO NEAREST WELL /Uy ft FOUNDATION /D�� ft PROPERTY LINEft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft UNDATION ft PROPERTY INE l ft <br /> SUMPS WIDTH ft LENGTH y ft DEPTH_e16 /�- ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION JO )J ft PROPERTY LINE S 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 /> MINIM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL 209 95_-7 97 <br /> SIGNED TITLE 1 DATE <br /> VA <br /> Q <br /> E Q / <br /> rH M ro- <br /> DEPARTMENT,USE ONLY c1 <br /> Application Accepted L. /�vv Date S /9 Z-DZ1b Area 1 Employee ID# <br /> Final Inspection By Date Z�� ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS P-55')Ulf fwd 1nteUSl'01- e' -eeDr -fEriu"r" ha� preyeY? 5e fo e o / <br /> pg-:0 t'be sed- c0eq. Okay/ P,-r PC— exisiln Slerrr OvM •for n�h�r �esiden4(e <br /> 5 CA W"I 19 ofIqrjaw <br /> PE SC Received heck#/ Amount Permit! " <br /> Code INFO B as Remitted Date Service Request# I oice# Permit ID# <br /> yaia its � $3�o I,q 1 <br /> 42-01 �P. L `" Wl�� O /fl_EWASTEWATERTRTM/NTSYSTEPERMIT J - <br /> 4/14/18 b 1� L Q'J� � '�f 1 O�r� / //VC� 2 � W i a� -f�-G e-Av S Q'✓�L L ���rCY <br /> .. <br /> / 0-1 �� <br />