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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) 953-7697FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS .�}.y� [� ,/ Cr m/ZIP <br />Lj <br />CROSS STREET Mt. i 1t+ r � • APN `� C1 V �-IO I -7 PARCEL SIZE <br />OWNER NAME�x _k +� �O 11� PHONE <br />i OWNER ADDRESS <br />`w /3�y 154 %��f p I W ��, � CiTVISTATE(7J/PJ �t <br />CONTRAC IGH_ I( 1•.. �N•6/t II Rr PHONE (..V�'�yi& i <br />CONTRACTOR ADDRESS "✓ 1�IfFA VW�1 CmISTATEZIP�(t LYS. "6y4t) <br />LICENSE D --C-42 ❑-C 36 OTHER_ NUMBER g5115� EXPIRATION DATE WIS <br />T���WATER TABLE DEPTH: J- 'lJ�R GEOGRAPHICAL INFORMATION: Coordinates X Y <br />= PERC TEST BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE: iSF WORK: {e NEW INSTALLATION , I REPAIRIADDITION _I ENGINEER DESIGNED IALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION _ <br />:INSTALLATIONa WILL SERVE: RESIDENCE COMMERrJAI ❑ OTHER <br />NUMBER OF LIVING UNITS: 3 NUMBER Or EMPLOYEES: <br />EPTIC TANK <br />nNUMBEROFBEDROOMS: <br />TYPE/hIFG T j L� CAPAOTY I LFII! gal #OF COM'ARTMENTS <br />❑ GREASETRAP <br />TYPEIMFG CAPACITY gal #OF COM?AP.TMENTS <br />w <br />C� <br />DISTANCE TO NEAREST: WELL \5D ft FOUNDATION IO"f ft PROPERTY LINE S ft <br />❑/ LIFT STATION <br />SIZE TYPE OF PUMP❑ PKO TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />Gi LEACH LINES <br />LEACHING CHAMBERSOF LINES_ LENGTH OF LINES 1�rJ) ft <br />DISTANCE TO NEAREST WELL 1� ` ft FOUNDATION lb t ft PROPERTY UNE J { R <br />❑ FILTER BED <br />WIDTH ft LENGTH It DEPTH ft <br />DISTANCE TO NEAREST W ELLft FOUNDATION ft PROPERTY UNE ft <br />❑ MOUNDED <br />WIDTH N LENGTH It DEPTH N <br />DISTANCE TO NEAREST WELLIt FOUNDATION R PROPERTY UNE It <br />❑ SUMPS <br />WIDTH It LENGTH ft CEPTH ft <br />DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY UNE It <br />❑ DISPOSAL PONDS WIDTH fl LENGTH R CEPTH R <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE ft <br />SEEPAGE PITS <br />NIWBER 3 WIDTH aL, tl ft L <br />DEPTH SL (t <br />DISTANCE TO NEAREST WELL t N FOUNCATION LD R PROPERTY UNE S 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 HULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />DEPARTMENL U3E ONLY `t <br />Application Accepted By /.. DateVl It tom_ Area ! Employee ID# <br />Final Inspection By Date D SPECIAL PERMIT- AppmvEd ty <br />Character of Soil to Depth of 3 Ft: Pit/Sump SoH Character. <br />COMMENTS ^�?, VJ S f F� R ; p <br />PE SC Received <br />Code INFO B <br />Check## Amount ate Permit/ Invoice # Permit IDS <br />Cash Remitted Service 9 <br />West <br />42 ONS17E WASTEWATER TRTMNr SYSTEM PERMIT <br />4/14!18 <br />?jj�/vr <br />?o2r <br />OA <br />/N TY <br />MFNT <br />