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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-KEFUNDABLE PERMIT JOB ADDRESS -2- 3 (/ CROSS STREET /[ !"oO h OWNER NAM CALL !UY 'JbJ-/6'J/ FOR INSPECTIONS LXPIRES 1 YEAR FROM UATE ISSUE i / ►/ee A CITl!Y//ZIP l U H S-1 AP �I r V PARCELSIZE�q OWNER1.11 �_s 99h PHONE -209- / Ire - d- o �� OWNER ADDRESS SGL rH CITY/STATE/ZIP �j �/ CONTRACTOR %1 1 e � PHONE .L �/L, - (J% ZO - Z 3 ! ^f Q CONTRACTOR ADDRESS Y ® / -2 (, CITY/STATE/ZIP LICENSE 1C-42 ❑I 1C-36 OTHER NUMBER ,�rV -3a EXPIRATION DATE i WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: CI NEW INSTALLATION I l REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE i REPLACEMENT I Zi h k L. OUT -OF -SERVICE SEPTIC SYSTEM ; DESTRUCTION j 4*110 k INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: �J SEPTIC TANK TYPE/MFG �� e� D CAPACITY 1- SO gal # OF COMPARTMENTS <� ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS / y ft DISTANCE TO NEAREST: WELL ft FOUNDATION O ft PROPERTY LINE ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES " LEACHING CHAMBERS # OF LINES ft ft ft ft ft LENGTH OF LINES _ ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMUM 48 HQUR ADVA CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697L� 1 SIGNED TITLE '// Q!ti ' e /� DATE ❑1 2021 NTY J DEPARTMEN USE ONLY Application Accepte By — �ZI Date i Area << Employee ID#�<� Final Inspection ByDate ( !' Z\ El SPECIAL PERMIT -Approved by Character of Soil to D pth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received Check#/ Code INFO Cash DISTANCE TO NEAREST WELL Permit ID# ft FOUNDATION FILTER BED WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION MOUNDED WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION SUMPS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION DISPOSAL PONDS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION SEEPAGE PITS NUMBER WIDTH DISTANCE TO NEAREST WELL ft FOUNDATION ft ft ft ft ft LENGTH OF LINES _ ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMUM 48 HQUR ADVA CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697L� 1 SIGNED TITLE '// Q!ti ' e /� DATE ❑1 2021 NTY J DEPARTMEN USE ONLY Application Accepte By — �ZI Date i Area << Employee ID#�<� Final Inspection ByDate ( !' Z\ El SPECIAL PERMIT -Approved by Character of Soil to D pth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received Check#/ Code INFO Cash Amount Remitted at Permit/ Invoice # Service Request # Permit ID# 9,3 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18