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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 <br />GHLL ZU F yb3-/by/ FOR INSPECTIONS <br />tXPIRES 9 YEAR FROM UATE ISSUE <br />JOB ADDRESS l �C'� <br />i <br />CITY/ZIP <br />TYPE/MFG <br />CAPACITY <br />Jil <br />0'-'I <br />J <br />I I <br />DISTANCE TO NEAREST: WELL <br />it <br />q c <br />CROSS STREET IS 4 / z/ <br />APN <br />l� <br />PARCEL SIZE <br />" <br />OWNER NAMEL✓ ��nAi4�[L-r <br />S Ic-- <br />PHONE <br />/ <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />WIDTH Ix , ft LENGTH <br />/ %� ft DEPTH ! f' ft <br />n ,'� <br />CONTRACTOR ✓,'� N���/I i �/✓'rnl <br />d��T is �. • <br />PHONE _, t <br />/� <br />❑ <br />CONTRACTOR ADDRESS �nv =/rf�' <br />WIDTH ft LENGTH <br />CITY/STATE/ZIP <br />LICENSE ❑1 C-42 ❑LIC -36 OTHER <br />NUMBER L � `� <br />EXPIRATION DATE <br />❑ <br />SEEPAGE PITS <br />WATER TABLE DEPTH: _ y ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # F -BU ILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED /AL ERN TIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM ;e DESTRUCTION V1 A t (K <br />INSTALLATION WILL SERVE: L% RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ! NUMBER OF EMPLOYEES: <br />91 <br />E3 SEPTIC TANK <br />TYPE/MFG L-� <br />CAPACITY /L4 41W <br />gal <br /># OF COMPARTMENTS f%� <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal <br /># OF COMPARTMENTS <br />WIDTH ft LENGTH <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft <br />PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />-41 <br />LEACH LINES <br />1 LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES �7 ft <br />/ <br />Date <br />DISTANCE TO NEAREST WELL / ' j' ft <br />FOUNDATION ft PROPERTY LINE L ft <br />❑ <br />FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />$sC)o <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY/LINE ft <br />SUMPS <br />WIDTH Ix , ft LENGTH <br />/ %� ft DEPTH ! f' ft <br />DISTANCE TO NEAREST WELL � (7 i1 ft <br />q <br />s / T — <br />FOUNDATION ! (_' ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />M/ UM 48 HPUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED <br />./ <br />TITLE DATE <br />1 I -7 / DEPARTMENT USE ONLY j Cf <br />Application Accepted By 1 ��y� �• Area Lf I Employee ID# Dh <br />Final Inspection By � Date ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Dept of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS 5y54eI,-A k17' -s ro Prnc;lYl, NZ, —'e 11 rj2e'y bc-S6j, >7� <br />,Nell w:4k hP�<k6i <br />PE <br />Code <br />Sc <br />INFO <br />Received <br />B <br />Chec <br />ash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />yya�� <br />,►s <br />$sC)o <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />