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S. 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 FxPIRES 1 YEAR FROM DAT I D <br /> JOB ADDRESS / <br /> CITY/ZIP ` <br /> CROSS STREET �� \ �— _ APN © `/ /�PARCEL SIZE <br /> - b <br /> � z <br /> OWNER NAME PHON O v <br /> OWNER ADDRESS CITY/STATE/ZIP Ce <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS A--CITY/STATE/ZIP <br /> LICENSE ❑I IC-42 DrIC-36 OTHER _ NUMBER XPIRATI,ON DATE <br /> WATER TABLE DEPTH: _ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT## LAND USE APPLICATION## <br /> TYPE OF WORK: I I NEW INSTALLATION 11 REPAIR/ADDITION 11 ENGINEER DESIGNED/ALTERNATIVE <br /> 17 REPLACEMENT !.I OUT-OF-SERVICE SEPTIC SYSTEM A DESTRUCTION :L-ilk r,/FSJ)Uk: h <br /> INSTALLATION WILL SERVE: 17 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 1-1 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 /> ❑ 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 /> MINWUM 48 H61A ADVANCE NOTICE RE UIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 ^� <br /> SIGNED TITLE DATEq;��_ ^d <br /> J <br /> OI UIV <br /> A T <br /> DEPARTMEN. U E ONLY �1 <br /> Application Accepted By G Date `C��7 v��aZTj Area 1 �or�� Employee ID#� <br /> Final Inspection By \ Date qZ c z,c_ ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: I Pit/SUmp Soil Character: <br /> COMMENTS <br /> PE SC Received Check Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B as Remitted Service Req est# <br /> qd3 J 0-75- <br /> 42-01 <br /> 7542-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />