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I <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-KEFUNDABLEI'ERMI1 <br />JOBADDRESS ,--7nqc <br />CROSS STREET <br />OWNER NA <br />•/D,Vf FUR INSPEG7IUNS CXPIKtS l TtAK I-KUM LJA It: Ibbut <br />CATTY/ZIP (1Y�=AL1+`�✓� <br />APN 7i�6 (VQ - ( O PARCEL SIZE <br />PHONE <br />OWNER ADDRESS' c CITY/STATE/ZIP <br />CONTRACTOR I 2�5 PHONE .I sda.`. -cls <br />CONTRACTOR ADDRESS ) �(i t CITY/STATE/ZIP ✓ "KMNt4 ie -,4 3( <br />LICENSE 11nC-42 ❑[7C-36 OTHER QCT NUMBER XPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: <br />❑ PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADC <br />I REPLACEMENT U OUT -OF -SEI <br />Coordinates X Y <br />� LAND USE APPLICATION # <br />ON Cl ENGINEER DESIGNED /ALTERNATIVE <br />CE SEPTIC SYSTEM LI DESTRUCTION <br />INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: (� I NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: l <br />SEPTIC TANK TYPE/MFG i V L CAPACITY ^Lawn'- Qal # OF COMPARTMENTS <br />E <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION Ie3 ft PROPERTY LINE "XO, ft <br />LIFT STATION SIZE �.: �[ <br />TYPE OF PUMPE�r4ndw5 ❑ PKG TX PLANT El SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES - LEACHING CHAMBERS # OF LINES LENGTH OF LINES <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />FILTER BED WIDTH d n7s ft LENGTH �� ft DEPTH ( 9 <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 />SIGNED <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Depth of 3 <br />COMMENTS --f&9- J <br />J <br />TITLE DATE La <br />Nr <br />TM ENT US ONLY 'I�j <br />Date Z Z Area � Employee ID# h <br />Date 9d � \v ❑ SPE IAL PERMIT - Approved by <br />Pit/Sump Soil Character: <br />PE <br />Code <br />DISTANCE TO <br />NEAREST <br />WELL If ;iri, <br />ft FOUNDATION La <br />1 <br />ft PROPERTY LINE <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />DISTANCE TO <br />NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />DISTANCE TO <br />NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />DISTANCE TO <br />NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />DISTANCE TO <br />NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <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 />SIGNED <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Depth of 3 <br />COMMENTS --f&9- J <br />J <br />TITLE DATE La <br />Nr <br />TM ENT US ONLY 'I�j <br />Date Z Z Area � Employee ID# h <br />Date 9d � \v ❑ SPE IAL PERMIT - Approved by <br />Pit/Sump Soil Character: <br />PE <br />Code <br />Sc Received <br />INFO <br />Chec Amount Date Permit/ Invoice # <br />Remitted I Service Request # <br />Permit ID# <br />Z 2 S �- <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />