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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 CAL (209)953-7697FOR <br /> I INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS ZZ ✓1 E-- I CIY/Z <br /> 0 2� r m <br /> CROSS STREET CV APN PARCEL SIZE <br /> 0 <br /> d <br /> OWNER NAMEPHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR /L ,ft Z., V -t��"`G n PHONE <br /> CONTRACTOR ADDRESS ` ` J"✓"��A� ^ CITYISTATE/ZIP ?i' J• J- S <br /> LICENSE DOC-42 0_7C-36 OTHER NUMBER-V EXPIRATION DATE ��� 3y/ �f�- <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: L NEW INSTALLATION IC REPAIR/ADDMON = ENGINEER DESIGNED/ALTERNATIVE <br /> L REPLACEMENT = OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: A) RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ElLEACH LINES EACHING CHAMBERS G G`�� #QF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAR WELL ft FFOODUUOATION ft PROPERTY LINE ft <br /> If FILTER BED WIDTH -S ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL / ft FOUNDATION ft PROPERTY LINE IV— ft <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> 5 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> �s„I ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> Y DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> VII n5 ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It <br /> (%[ DISTANCE TO NEAREST WELLft 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-^PLEASE CALL 209 953-7697 <br /> SIGNEDTITLE L-���7 r/�`� DATE 7� <br /> AYMENT <br /> ECEIVED <br /> EB 12 2021 <br /> 117 S JOAQUIN COUNTY <br /> VIRONMENTAL <br /> LTH DEPARTMENT <br /> ] TMENT 5,,E_ONLY �(� <br /> Application Accepted BU�h V Date - Area� I Employee ID# <br /> Final Inspection By Date IA ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to De th of 3 Ft: it/Sump SQiI Character: <br /> COMMENTS r LLV <br /> 'Ca • <br /> c71j�- <br /> S 'c .!-'1S i� f' ✓2 i' �',n'1� <br /> PE S Received Check#/ Amoun Date Perm By <br /> Invoice PermitlD# der <br /> Code INFO Remitted ervice Re uest# <br /> I Z ZI p ("("►r <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />