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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 /EXrPIRES/J1<YEAR FROM DATE ISSUED <br /> JOB ADDRESS 0, Q � + I (� CITY/ZIP I <br /> 1 m <br /> CROSS STREET "c' n APN FO'Do)/)D PARCEL SIZE <br /> v <br /> OWNER NAME ) I / I �`1 ` PHONE <br /> OWNER ADDRESS3cx71� )� J,Gr SSS CITY/STATE/ZIP f 41,1V (�(l S 3�Ll <br /> CONTRACTOR ��'�INLr/.f� L)C_ I? /� (� PHONE <br /> CONTRACTOR ADDRESS I J/ ��61, (Lim T\(� C CITY/STATE/ZIP -'T (/Cu <br /> LICENSE L1C-42 ❑❑C-36 OTHER R NUMBER L > EXPIRATION DATE <br /> WATER TABLE DEPTH: /PSS �l)Gr n I V ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> LINSTALLATION WILL SERVE: A RESIDENCE ❑ COMMERCIAL El OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: r ,r NUMBER OF EMPLOYEES: <br /> t <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 /> LEACH LINES LEACHING CHAMBERS #of LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> FILTER BED WIDTH �IS ft LENGTH SS TT ft DEPTH LO 042 ILL T7 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 1U r ft PROPERTY LINE J �Iw ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft 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 /> SIGNED TITLE DATE <br /> I <br /> - - 1 ! <br /> I <br /> I <br /> NAL <br /> �AT D ? .T IE T <br /> DEPARTMENT,USE ONLY <br /> Sas- .�aN S /l,' <br /> Application Accepted (By _ Date ' � Area � Employee ID# � <br /> Final Inspection By Y} Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: l Pit/ mp Soil Character: <br /> COMMENTS ��;I�inc .Sbitl;,� FvII replefG['mey7'T <br /> PE SC Received Check#/; Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Cash Remitted Service Request# <br /> 5-2 W 00 S 7Sol <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/16 <br />