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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN .IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT , CALL ((209) 953 ;7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS � �j // CITY/ZIP > CROSS STREET / � alp' APN _� �b�LI LI a � PARCEL SIZE i �J ✓ J� > / OWNER NAME - �/ � PHONE ��% � -�' �.�� /� /� � , OWNER ADDRESS �, '�� V\„1� / CITY/STATE/ZIP CONTRACTOR �/ L/G'l.�itJ�//�� i�� I /./I7 /%� �.�/�i - PHONE CONTRACTOR ADDRESS hblj'�C. � � /7 LiTJI/� �� CITY/Sl Tom' ,,rr -7 LICENSE ❑❑C-42 ❑❑C-36 OTHER � NUMBER JD 1 EXPIRATION DATE �2-” 3� —�[/ WATER TABLE DEPTH: 70 � Q O ft GEOGRAPHICAL INFORMATION: COOrdlnateS X ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # . — TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DE; ❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION V INSTALLATION WILL SERVE: � RESIDENCE ❑ COMMERCIAL > ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: J NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY ❑ GREASE TRAP TYPE/MFG CAPACITY DISTANCE TO NEAREST: WELL O LIFT STATION SIZE TYPE OF PUMP n ft FOUNDATION O PKG TX PLANT /ALTERNATIVE gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES ❑ LEACHING CHAMBERS Received Check#/ Cash # OF LINES Date Permit/ Service Request # Invoice # Permit ID# '-1�j0 DISTANCE TO NEAREST WELL � ft FOUNDATION FILTER BED WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION MOUNDED WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION SUMPS WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION DISPOSAL PONDS WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION r•. � / ft SEEPAGE PITS NUMBER ,� WIDTH DISTANCE TO NEAREST WELL ft FOUNDATION � li fi LENGTH OF LINES ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH �_ � / ft ft PROPERTY LINE S � ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINI M 48 HOU ADV NCE NOTICE RE UIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 SIGNED TITLE � � �� DATE � ' �� —�� DEPARTMENT U- E ONLY Application Accepted y �y =�G Date -� �3 �� Area � � Employee ID# D� Final Inspection By � Date �i 7/ ,� SPECIAL PERMIT -Approved by (',(L Character of Soil to Depth of 3 F : Pit/Sump Soil Character: COMMENTS S�cc,c,.� �cV;Mf }', P/ 1s �,�/>id1 �6 lac-cl" �11heS - S('c' c: ^S��lfc; }lol� <AOo�3L1�6 ��bpi�✓E�L'� b�' pT I �T ��pr�Al`n�t}ar, ��is3`►nti 1�h�s � /�r�Uun. F�,il,h5 S�5-fe�� PE Code SC INFO Received Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# '-1�j0 j►� �sv� � �3 � H d d ;, I<�? 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18