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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> S,*J JOAQU`N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 9;j-7 R97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> / 155 <br /> JOB ADDRESS � TLY <br /> � � � CITY/ZIP <br /> CROSS STREET C_P o%(i.... �S;a / T/ /nI APN DD PARCEL SIZE (�.U y /������ p <br /> L t V�✓� PHONE 211�i - -��15-7 v <br /> OWNER NAME -- -- <: /CC,- V. <br /> OWNER ADDRESS CITYISTATE/ZIP <br /> CONTRACTOR Azi PHONE <br /> CONTRACTOR ADDRESS /fes L(/ CITY/STATE/ZIP <br /> LICENSE DIC-42 ❑!'1C-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 EPAIR/A DITION i ENGINEER DESIGNED/ALTERNATIVE <br /> f i REPLACEMENT F-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCENseCOMMERCIAL ❑ 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 I A #OF LINES 2 LENGTH OF LINES 100 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 /> J DISTANCE TO NEAREST WELL ft FOUR' TION ft PROPERTY LINE C ft <br /> �Q SEEPAGE PITS NUMBER � WIDTH ,1 ft DEPTH ?_J ft <br /> ` DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I HAVE PREP RED 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 DV E NOTICE E UIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE (S. DATE <br /> Opp <br /> A LU <br /> DEPARTMENT USE ONLY <br /> Application Accepted Date Zp?D Area EmployeQ1� <br /> Final Inspection By Date -ZD ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 t: Pit/Sump Soil Character: <br /> COMMENTS jt10 .RECD /14i_.. eCU CP Or i5',. _CSC �Sft � )S Ole <br /> 1 <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO By Cash Remitted Date Service Request# Invoice# Permit ID# <br /> 4219 -z51 I0•2io^zo SQL 00 vi <br /> 42-01 !' I I I IJ O �l f ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 lll��� ���777►►► K ✓ I <br />