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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205.(209)4683420 <br /> NON-REFUNDABLE PGERMITy� d� CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I lP0 +',�1itI CrrY21P S 7-DC k-TOA9 Ij Cz-1_S- <br /> GROSS <br /> y <br /> G ? <br /> CROSS STREET SIS•N l!At /OkN.A� APN �OI ��— ) ' /PA`R/CgELSIZE J• 5- „ o <br /> OWNER NAME A-t r&ZA l3i 1 e—r .�f�S PHONE. yp T 1 (1 7-2— <br /> OWNER <br /> OWNER ADDRESS -S N-mE CrrY/STATE/ZIPP <br /> CONTRACTOR _LXV C �O/1'V4 �E1Q0Jf�A)W1L-/V I R L- PHONE 3 tol—0T-1 <br /> —GS <br /> CONTRACTOR ADDRESS D-7 yi. O A'K- ST CrrY/STATE/ZIP LO V t C�A 972-4-0 <br /> LICENSE ](:IC-42 110C36 OTHER �tG NUMBER Z I S I EXPIRATION DATE -4 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # IBUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDrnON ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT 11 OUT-OF-SERVICE SEPTIC SYSTEM 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ 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 TYPEfMFG 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 J LEACHING CHAMBERS #OF LINESLENGTH 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 /> MINIMUM 4WHOUR AD VA <br /> JVCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE '-f`1 -`2 <br /> SIN C <br /> /VlyFiyTUly1Y <br /> DEPARTMENT USE ONLY y� / pART4%v?- <br /> Application Accepted ByyL� Date"//S7a I Area �GC% Employee ID# A(, <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Chec Amount Permit/ <br /> Code INFO B ash Remitted Date Service Request# Invoice# PermitlD# <br /> 'LlaDD s'23 n ( <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />