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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 XPIRES 1 YEAR FROM DATE ISSUE <br />JOB ADDRESS �� CITY/ZIP70�� --A <br />C r <br />CROSS STREET APN I D j PARCEL SIZE -1 I <br />OWNER NAME ( � , PHONE <br />OWNER ADDRESS 15 /U"' <br />E/ CITY/STATE/ZIP <br />CONTRACTORL(�L�1a44_r_"JaC /- Z/1,4,n ��/,� "t/ 6J - PHONE <br />CONTRACTOR ADDRESS %U "eL-L ,/�f7 CITY/STATE/ZIP <br />LICENSE ❑ _C-42 LI -C-36 OTHER NUMBER EXPIRATION DATE%/ <br />- <br />WATER TABLE DEPTH: U ft GEOGRAPHICAL INF MATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # 004DRAND USE APPLICATION # <br />TYPE OF WORK:_ NEW INSTALLATION _ REPAIR/ADDITION - ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT _ OUT-OF-SERVI PTIC SYSTEM _ DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COM CIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROO S: /� /� NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG �4 '/ TY �lA �// gal # OF COMPARTMENTS -2- <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELLA��7� It FOUNDATION 4j�: '-7L ft PROPERTY LINE S <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />D <br />LEACH LINES <br />C LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />� <br />�i'D <br />DISTANCE To NEAREST WELL <br />It FOUNDATION ft PROPERTY LINE It <br />❑ FILTERBED <br />WIDTH ft <br />LENGTH ft DEPTH It <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE It <br />❑ MOUNDED <br />WIDTH ft <br />LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH It <br />LENGTH It DEPTH It <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft <br />LENGTH ft DEPTH It <br />SEEPAGE PITS <br />DISTANCE TO NEA ST WELL It .FOUNDATION ft PROPERTY IyNE ft <br />NUMBER WIDTH_;; . ft DEPTHJ� ft <br />_k <br />DISTANCE TO EAREST WELL <br />, ft FOUNDATION /// 1 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 <br />RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />IN164& 48 <br />HOUR �AMe1 NOTIC=QUIRED <br />FOR INSPECTIONS -PLEASE CALL (20 9) 9553-7697 <br />SIGNED <br />TITLE (f_ 612 DATE Z ' 2_��- -2_1 <br />PAYMENT <br />RECEIVED <br />FEB 2 2 2021 <br />JOAQUIN COUNTY <br />WIRONMENTAL <br />LTH DEPARTMENT <br />DEPARTMENT USE ONLY ) <br />Applicati n Accepted B Date Area A� Employee ID#� I C< <br />Final Inspection By Date 3 Z ❑ SPECIAL PERMIT - Approved by <br />Character of Soil; eplh of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS / d S , <br />PE SC Received Check#/ Amount PermiU <br />Code INFO A By- Cash Remitted Date Service Re uest # <br />Invoice # Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />