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i <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE -STOCKTON CA 95205 -(209) 468-3420 <br />JOB ADDRESS <br />`40d -f 0 V f FOR INSPECTIONS <br />CITY/ZIP <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION EPAIR/ADDMON ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT _ OUT -OF -SERVICE SEPTIC SYSTEM _ DESTRUCTION <br />INSTALLATION WILL SERVE: 1KRESIDENCE ❑ COMMERCIAL ElOTHER <br />NUMBER OF LIVING UNITS: �/� �NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG &/�,u& V �UMl CAPACITY gel # OF COMPARTMENTS <br />�v. <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT L] SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />M—LEACH LINES <br />I- LEACHING CHAMBERS <br />9 <br />D <br />CROSS STREET <br />APN +1�dl - a <br />R FOUNDATION ft PROPERTY LINE It <br />PARCEL SIZE ' <br />%' <br />OWNER NAME L/` rse4 <br />WIDTH ft LENGTH <br />PHONE <br />�F• <br />OWNER ADDRESSJ.�'A L'1^' �-� <br />—CITY/STATE/ZIP <br />It FOUNDATION ft PROPERTY LINE <br />• <br />❑ MOUNDED <br />It DEPTH ft <br />y C® <br />CONTRACTOR <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE Alii <br />CONTRACTOR ADDRESS <br />J <br />CITY/STATE/ZIP <br />It DEPTH <br />°? <br />LICENSE LJ _C-42 IJ -C-36 OTHER <br />h�7 <br />NUMBER C� 7O� EXPIRATION DATE <br />It FOUNDATION ft PROPERTY LINE �S'AAI <br />n <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />It DEPTH PA <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION EPAIR/ADDMON ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT _ OUT -OF -SERVICE SEPTIC SYSTEM _ DESTRUCTION <br />INSTALLATION WILL SERVE: 1KRESIDENCE ❑ COMMERCIAL ElOTHER <br />NUMBER OF LIVING UNITS: �/� �NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG &/�,u& V �UMl CAPACITY gel # OF COMPARTMENTS <br />�v. <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT L] SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />M—LEACH LINES <br />I- LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES <br />DISTANCE TO NEAREST WELL��%(j <br />R FOUNDATION ft PROPERTY LINE It <br />❑ FILTER BED <br />WIDTH ft LENGTH <br />It DEPTH <br />�F• <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION ft PROPERTY LINE <br />• <br />❑ MOUNDED <br />WIDTH It LENGTH <br />It DEPTH ft <br />y C® <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE Alii <br />❑ SUMPS <br />WIDTH It LENGTH <br />It DEPTH <br />°? <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION ft PROPERTY LINE �S'AAI <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />It DEPTH PA <br />VAN <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION ft PROPERTY LINE <br />C <br />��, of T. <br />JK SEEPAGE PITS <br />NUMBER _� WIDTH <br />J % ft DEPTH ��. J ' <br />pd nr T� I 1 <br />-'jT <br />DISTANCE TO NEAREST WELL /,!;-/J' <br />ft FOUNDATION % ' a-' ft PROPERTY LINE -.2 ft <br />MFNT <br />1 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 />COMMENTS <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />