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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 CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET <br />OVMER <br />Y ) <br />APIN ,I O 5 CO PARCEL SIZE ' � , <br />ONNER ADDRESS ` 11 `- CITYISTATEIZIP <br />CONTRACTOR PHONE <br />CONTRACTOR, ADDRESS / CITY/STATEIZIP <br />LICENSE �C-42 C.16 OTHER NUMBER �59� �_XPIRATON DATE <br />(\ i <br />WATER TABLE DEPTH: h GEOGRAPHICAL INFORMATION: Coordinates X Y <br />C PERC TEST # <br />LEACHING CHAMBERS <br />BUILDING PERMIr# LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEw INSTALLATION REPAiRIADDITION <br />ENGINEER DESIGNED /ALTERNATIVE <br />WELL <br />REPLACEMEN <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL SERVE: <br />TIDENCE COMMERCIAL <br />OTHER <br />NUMBER OF LIVING UNITS: <br />v <br />NUMBER OF BEDROOMS:NUMBER <br />OF EMPLOYEES: <br />SEPTIC TANK <br />TYPEIMFG <br />C' CAPACITY ZOO <br />gal # OF COMPARTMENTS �Z <br />❑ GREASE TRAP <br />TYPEIMFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL 1-' $ITP R FOUNDATION Z O r <br />ft PROPERTY LINE ZO , ft <br />❑ LIFT STATION <br />SIZE <br />TYPE OF PUMP PIG i1 ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE To NEAREST <br />WELL <br />R FOUNDATION <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />❑ DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />LENGTH OF LINES _ <br />ft PROPERTY LINE <br />DEPTH <br />R PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />ft <br />ft <br />ft <br />ft <br />It PROPERTY LINE <br />DEPTH <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 />7DEPARTMENT US ON Y <br />Application Accepted By Date ' � Area ' Employee ID#IJA_ <br />Final Inspection eyDate 1' SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 1 Ft: Pi1/Sump Soil Character: <br />COMMENTS d Per --I r Y <br />Siarfd A -/le- .3-_/z-•ca�...s. - - --- <br />PE SC Received Chec Amount Date Permit/ Invoice # Permit ID# <br />Code INFO Remitted Service Request # <br />a� il� -f3o(� •y - V �, <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />