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A <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-KEFUNDABLE PERMIT L;ALL . . y53 -/6y/ FOR INSPECTIONS LXFIRE InYEAR FROM UATE ISSUE <br />JOB ADDRESS pp y CITY/ZIP L J <br />CROSS STREET W / APN OJ 5 7 O 1 / % PARCEL SIZE io, G <br />OWNER NAME PHONE <br />OWNER ADDRESS �J U G�%� S I p CITY/STATE/ZIP <br />CONTRACTOR) PHONE <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE ❑UC -42 1111C-36 OTHER NUMBEREXPIRATION DATEL� <br />DEPARTMENT USE ONLY pP <br />Application Accepted By Date S' r i Area t. �� Employee ID# /�I <br />Final Inspection By 4 Date ✓��l6rL� ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS 0;j i>oVFGf b,/ P�r��1Crk J2PA��;cl�i�h S 5�e5iy �iC�! I�1S fuoclb'vill <br />-7 <br />ti•! 54 V," rr I n .r�)2 be- 000 <br />PE <br />Code <br />- <br />Received <br />B <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />❑ PERC TEST # <br />BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: <br />❑ NEW INSTALLATION X-1 REPAIR/ADDITION <br />I ENGINEER DESIGNED /ALTERNATIVE <br />409 <br />❑ REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM <br />I DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING <br />UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF tMPL"O. <br />❑ SEPTIC TANK <br />TYPE/MFG CAPACITY <br />gal #OFCjnC1S1%1Srjfto <br />L3 GREASE GREASE TRAP <br />TYPE/MFG CAPACITY <br />gal # OF CEJ AYT ENNTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION <br />n <br />ft PROPERTY LIN `+ 2021 ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ <br />SAND OIL SEPQ� " MY TEM) <br />HEALTj�RONMENTAl <br />�'ARTMENT <br />❑ LEACH LINES <br />I LEACHING CHAMBERS # OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL FOUNDATION <br />ft PROPERTY LINE ft <br />&4J- FILTER BED <br />/ft J <br />WIDTH 'V'0 � <br />ft LENGTH (p® <br />DEPTH ft <br />DISTANCE TO NEAREST WELL 1&6 ft FOUNDATION /P - <br />ft PROPERTY LINE <br />(3 MOUNDED <br />WIDTH ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <br />WIDTH ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />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 />MINI <br />48 HOUR ADVANQE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED <br />TITLE % 0 <br />n <br />DATE 9�e �, <br />DEPARTMENT USE ONLY pP <br />Application Accepted By Date S' r i Area t. �� Employee ID# /�I <br />Final Inspection By 4 Date ✓��l6rL� ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS 0;j i>oVFGf b,/ P�r��1Crk J2PA��;cl�i�h S 5�e5iy �iC�! I�1S fuoclb'vill <br />-7 <br />ti•! 54 V," rr I n .r�)2 be- 000 <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />ash <br />Amount <br />Remitted <br />Dat <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />409 <br />1,7,7257 <br />�300 <br />S <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />T <br />