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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 z- f CITY/ZIP <br /> 33x09 ) /� / <br /> CROSS STREET J� APN CJS PARCEL SIZE 1 -1 <br /> OWNER NAME PHONE 6 ? 7 y )y A <br /> OWNER ADDRESS 1 e ( CITY/STATE/ZIP <br /> CONTRACTOR A P,o/C n/'� ) �I L ,/Se W�"� PHONE 2- a S ) � � J� " L"I, 31 <br /> CONTRACTOR ADDRESS 1 Vo �� ��/�� e'✓ G/�" <br /> / ( CITY/STATE/ZIP <br /> LICENSE ❑ C-42 1111C-36 OTHER /4 NUMBER l J yI_� EXPIRATION DATE ���� <br /> WATER TABLE DEPTH: I� ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> C PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: LI NEW INSTALLATION I <br /> d REPAIR/ADDITION I! ENGINEER DESIGNED/ALTERNATIVE <br /> del REPLACEMENT )(601 Irle OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: Z RESIDENCE C 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 '� -3 (, #OF LINES LENGTH OF LINES ft <br /> DISTANCE To NEAREST WELL /ZQ ft FOUNDATION 41' PROPERTY LINE 'm r 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 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 TITLE C[?r�h"/ �✓" DATE s J zJ <br /> EC IV <br /> iiik L <br /> N <br /> DEPAR M ENT <br /> A+ <br /> 9 DEP TMENT U E ONLY {} <br /> Application Accepted By G� mac— Date g 1S ,,4)d0 Area Employee ID# DA <br /> Final Inspection By Date C SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTSc, o-( )P4iCl1 Iri Pl�. <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B.V C sh Remitted Service Request# <br /> L)d, <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />