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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-REFUNDABL5 PERMIT CAL 209) 953-7697 FOR INSPECTIONS EXPIRESo1 YEAR FROM DATE ISSUED <br />JOBADDRESS CITY/ZIP <br />CROSS STREET 4A d /-/-✓ APN C2(/ 5 —3 0y l l PARCEL SIZE <br />OWNER NAME�/�'i�L T7�iLjie•L/��T/ y PHONE <br />OWNER ADDRESS �``�Vt/L/i YTJT CITY/STATE/ZIP <br />ell I CONTRACTOR i � � PHONE - / ,✓ /t <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />` _ Z621N �)/JJ <br />LICENSE ❑OC42 [1_7C-36 OTHER_ NUMBER EXPIRATION DATE /" � `��-�/ <br />WATER TABLE DEPTH: <br />ft <br />GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # <br />BUILDING PERMIT# LAND USE APPLICATION # <br />TYPE OF WORK: <br />L NEW INSTALLATION <br />EPAIR/ADDrnON F. ENGINEER DESIGNED /ALTERNATIVE <br />L REPLACEMENT <br />C OUT -OF -SERVICE SEPTIC SYSTEM L DESTRUCTION <br />INSTALLATION WILL <br />SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: <br />NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />A2�SEPTIC TANK <br />TYPE/MFG <br />\/ CAPACITY I gal # OF COMPARTMENTS 'nZ� <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />l <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE .S '}' ft <br />❑ LIFTSTATION <br />SIZE TYPE <br />OF PUMP ❑ PKGTXPLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />{�' LEACH LINES <br />❑ LEACHING CHAMBERS <br />#oF LINES LENGTH OF LINES 1 U ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION it PROPERTY LINE y/ft <br />❑ FILTERBED <br />WIDTH <br />ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE It <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE It <br />❑ SUMPS <br />WIDTH <br />ft LENGTH ft DEPTH it <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE It <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH ft DEPTH it <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE it <br />SEEPAGE PITS <br />NUMBER <br />WIDTH Ij / it DEPTH " ft <br />DISTANCE To NEAREST <br />WELL-''rI� �-� ft FOUNDATION /-D 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 />Application Accepted By <br />Final Inspection By� <br />Character of Soil to Depth of <br />VRI/YJf-G{i /IVIYJ'!'LCNJG VNLL GVJ JJJ'/VJ/ <br />TITLE (:�LA DATE - <br />WENT <br />'CEIVED <br />22 2021 <br />N COUNTY <br />DEPARTMENT <br />Area ` ` Employee ID# ;�)q rl <br />❑ SPECIAL PERMIT -Approved by <br />Character: / <br />IS <br />PE SC Received Check#/ Amount ate Permit/ Invoice # Permit ID# <br />Code INFO Am, . C s Remitted I Service Re uest# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4114/18 <br />