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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 <br />CALL <br />209 953-7697 FOR INSPECTIONS <br />EXPIRES 1/YEAR FROM DATE ISSUE[ <br />JOB ADDRESS s <br />C - e <br />c��^ ' <br />CITY/ZIP - ✓ 1. <br />C.3,40y <br />�� <br />P' <br />tet -.e <br />CROSS STREET <br />APN <br />PARCEL SIZE c S' <br />OWNER NAME �e T <br />PHONE cQ 2 � �E�� <br />�� <br />475 <br />OWNER ADDRESS i^ ,- <br />, e- <br />CITY/STATEIZIP <br />r . ✓ <br />CONTRACTOR S e� <br />PHONE <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE ❑LJC-42 ❑OC -36 OTHER <br />NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: �: /IV ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # T BUILDING PERMIT # LAND USE APPLICATION # <br />TYRE OF WORK: I><- NEW INSTALLATION ii REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />CI REPLACEMENT IJ OUT -OF -SERVICE SEPTIC SYSTEM CI DESTRUCTION <br />INSTALLATION WILL SERVE: n LX -RESIDENCE ❑ COMMERCIAL <br />/� 11 OTHER <br />NUMBER OF LIVING UNITS: aG /,I NUMBER OF BEDROOMS: �i NUMBER OF EMPLOYEES: <br />AC SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />❑ LIFTSTATION <br />LEACH LINES <br />❑ FILTER BED <br />❑ MOIfNDED <br />❑ SUMPS <br />DISTANCE TO NEAREST: WELL ft <br />SIZE TYPE OF PUMP <br />CAPACITY / �/� gal #OFCOMPARTMENTS <br />CAPACITY gal # OF COMPARTMENTS <br />FOUNDATION ft PROPERTY LINE ft <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />l <br />❑ LEACHING CHAMBERS # OF LINES /�3 LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL V-' ©� ft FOUNDATION V (r ft <br />(� PROPERTY LINE S , ft <br />WIDTH ft LENGTH ft DEPTF <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft <br />WIDTH ft LENGTH ft DEPTF <br />DISTANCE TO NEAREST WELL <br />WIDTH ft LENGTH <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft <br />ft DEPTF <br />PROPERTY LINE <br />PROPERTY LINE <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />ft <br />ft <br />ft <br />ft <br />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 �J ft <br />DISTANCE TO NEAREST WELL/y ft FOUNDATION' ft PROPERTY LINEftft <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 <br />Final Inspection By <br />Character of Soil to)e <br />COMMENTS 2 <br />Vr% IIYJr'L--t.IIV/YJ - rLCNJG tr/YLL (AV -71 <br />TITLE Ci`Z—/7,c� DATE <br />DEPARTMENT U E OAILY / <br />Date Area r <br />Date 1 qZJ ❑ SPE <br />3 Ft.f Pit/Sump Soil Character: <br />041. <br />4f 4 Employee ID#� <br />PERMIT - Approved by <br />PE SC <br />Received Chec /mount <br />Date <br />Permit/ <br />Invoice # Permit ID# <br />Code INFO <br />By_ Cas <br />Remitted <br />Service Request # <br />S ez 0 O acl <br />42-01 �k / X-)7—� �^ ONSITEMN <br />,WASTEWAT R TR SYSI�M PERMIT <br />4/14/18 l 6 q <br />�1 U�'�1�✓��� or e ng C. t ei4vV <br />