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c' 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 2^09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS in a 0 Y L4�H� PO S 1� CITY/ZIP C v <br /> CROSS STREET �r r r1� APN flJ ( 04/" 0 PARCEL SIZE o <br /> OWNER NAME / PHONE <br /> OWNER ADDRESS (24oc> CITY/STATE/ZIPq7PHy A( ] <br /> T J� <br /> CONTRACTOR 160 , 1 kC .6,4 e4<1i d--r- x `- PHONEJ V l/D�5 d <br /> CONTRACTOR ADDRESS g�Y_6 �O CITY/STATE/ZIP M co 7`��1�T )e.4 515331 <br /> LICENSE ❑CIC-42 01_IC-36 OTHER NUMBE EXPIRATION DATE � at2 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION _ REPAIR/ADDITION IJ ENGINEER DESIGNED/ALTERNATIVE <br /> IJ REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM Li DESTRUCTION <br /> INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: - 3 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 /> EACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES (4o ' ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION �T t ft PROPERTY LINE �!�) ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 3 I, (1 ft DEPTH dS ft <br /> DISTANCE TO NEAREST WELL �;n I ft FOUNDATION ft PROPERTY LINE ft <br /> 1 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 ADVA TICS REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697^^ <br /> SIGNED TITLE, t-r r DATE <br /> EPA R TMEW)USAC ONL Y <br /> Application Accepted By Date Area Employee I <br /> Final Inspection By Date 211104LAL PERMIT-Approved <br /> ❑ SPE <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS T ��, �( c,� fT[rel. A i t- <br /> 9 2nq, <br /> ,IpgQUI <br /> Ai <br /> t4 p <br /> PE SC Received ec Amount ate Permit/ Invoice# HSI$ <br /> Code INFO B Cash Remitted Service est# � <br /> O �� v� 21 tZT <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4114/18 <br />