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c � <br /> 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 EXPIRES 1 YEA FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP -] <br /> CROSS STREET f/ l"/'/ , [�y'A ,1A1/ APN ��c-.i f 1 o Oa PARCEL SIZE I / p <br /> OWNER NAME - v t,S PHONE� V� <br /> OWNER ADDRESS S C-1G't'1 CITY/STATE/ZIP <br /> CONTRACTOR G ti l 6A1,A jLPHONE g/93L�,�)-/L�y ,✓/� <br /> CONTRACTOR ADDRESS , ��2_� CITY/STATE/ZIP <br /> LICENSE ❑0C-42 ❑11C-36 OTHER / l NUMBEREXPIRATION DATE,//�i <br /> WATER TABLE DEPTH: "7 l C.� ft GEOGRAPHICAL INFORMATION: Coordinates X Y- <br /> F- PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION EPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ESIDENCE _ COMMERCIAL L1 C 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 /> I�ILi LEACH LINES LEACHING CHAMBERS U #of LINES/�_ LENGTH OF LINES ft <br /> v v DISTANCE TO NEAREST WELLy ft FOUNDATION / �� 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 NEAP EST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> to SUMPS WIDTH ft LENGTH /b ft DEPTH i ft <br /> \ DISTANCE TO NEAREST WELL_/nd OUNDATION L' ft PROPERTY LINE S �' 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 /> MI UM 48 HOUfMDONCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br /> SIGNED TITLE (i (/ DATE&>-/ � I <br /> A J71 IV rim <br /> HEALTHD P <br /> DEPARTMENT•US ONLY <br /> Application Accepted Byn i Date 17 ,� Area l/ Employee ID# <br /> Final Inspection By ��• " Date < C SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS (,:,,Iln� �vs�f'►� , 1=�xlsfi���, �?��f'r� a�^ ��Ci3�1'rY lot <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO BW Cash Remitted Service Request# <br /> 3 ib IIS 3vC 17 tl y `� <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />