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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-KEFUNDABLE PERMIT (;ALL <br />-11 <br />JOB ADDRESS _iN (�� f- } �� ✓y^I <br />CROSS STREET / . m2 0'r --_P L)o v LI S <br />OWNER <br />Y53 -15Y/ FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI <br />jCIrLTY/ZIP <br />APN i ✓� /fJ�`� _?0 PARCEL SIZE L I <br />PHONE <br />OWNER ADDRESS 4CITY/STATE/ZIP <br />+ 1 _ 1 <br />CONTRACTOR _04 4� S t!� G: L �� h I' PHONE lY= — d <br />CONTRACTOR ADDRESS �L��' �7 ��) CITY/STATE/ZIP L^� �% ✓'Y : �; /' l i �: <br />LICENSE ❑;. C-42 ❑1jC-36 OTHER NUMBER t �) S� `� EXPIRATION DATE a `- <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: COOr inates X Y <br />❑ PERC TEST # BUILDING PERMIT # t Ci Z LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />_ REPLACEMENT J OUT -OF -SERVICE SEPTIC SYSTEM h DESTRUCTION <br />INSTALLATION WILL SERVE: ' RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG / J ' L <br />CAPACITY gal <br /># OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal <br /># OF COMPARTMENTS <br />I S 4 ' <br />DISTANCE TO NEAREST: WELL '} <br />ft FOUNDATION ft <br />PROPERTY LINE (J 1 ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />0 LEACH LINES <br />5 LEACHING CHAMBERS <br />Received <br /># OF LINES <br />LENGTH OF LINES _S S ft <br />DISTANCE TO NEAREST <br />WELL <br />I S 4 ' <br />ft FOUNDATION PROPERTY LINE I ft <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />Invoice # <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />�j <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />1 SEEPAGE PITS <br />NUMBER <br />WIDTH o� <br />(: /j ft <br />DEPTH 1 ft <br />DISTANCE TO NEAREST <br />WELL <br />/ I <br />ft FOUNDATION 1,") 1 <br />ft PROPERTY LINE C I 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 />II111111I1 III -fV 1/ I\ M✓ jErl VV/L 111V 11VL I\L VII\L✓ I VI\ 11vJr L/V I IV/1J - I-LLI.IJL F1LLLV.7 JJ I1 <br />SIGNED TITLE (v�.:7c�T o DATE _ s <br />T <br />g)j_DLEEPARTMENTIUSiONLY <br />Application Accepted t Date .� Area L Employee ID# <br />Final Inspection By ��- �Y (�— Date S ( 1✓ ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS_Z6a: fj- <br />PE <br />SC <br />Received <br />Amount <br />Code <br />INFO <br />By <br />ash <br />Remitted <br />DatePermit/ <br />Serv' a Request # <br />Invoice # <br />Permit ID# <br />1 <br />2 <br />�j <br />1 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/16 <br />