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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 GALL "109 953-7697 FOR INSPECTIONS XPIRE4 1 YEAR ATE ISSUE[ JOB ADDRESS CITY/ZIP DEPTH �JFRQOM CROSS STREET ((�� APN O 'j 9 - -I"+- WELL PARCEL SIZE OWNER NAME- '�G�y (I(/; [S C/C�Li) PHONE MOUNDED WIDTH ft OWNER ADDRESS CITY/STATE/ZIP ft PROPERTY LINE � CONTRACTOR Z > / ll" -44/ (� PHONE q' WELL ENVIRONMENTf�L CONTRACTOR ADDRESS J�fJ�/ � jy1/( ly�7.G��, CITY/STATE/ZIP LICENSE �❑C-42 ❑❑C-36 OTHER NUMBER , �� EXPIRATION DATE ' �3 2j WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION X REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE ❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFTSTATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL SIZE TYPE OF PUMP CAPACITY CAPACITY ft FOUNDATION ❑ PKG TX PLANT LEACH LINES ❑ LEACHING CHAMBERS # OF LINES 1 DISTANCE TO NEAREST WELL ft FOUNDATION ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft ft PROPERTY LINE DISTANCE TO NEAREST WELL ft ft FOUNDATION ❑ MOUNDED WIDTH ft LENGTH ft PROPERTY LINE DEPTH _ DISTANCE TO NEAREST WELL ENVIRONMENTf�L 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 gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ft ft ft ft I 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. SIG Application Accepted Final Inspection By_ Character of Soil lt�to��D COMMENTS mac% V/\ TITLE 61 DATE c bPAKTMENTUS ONLY w u Date Area q Employee ID# Date ❑ SPEC AL PERMIT - Approved by 3 Ft: Filksurrp Soil Character: et, PE SC Receive Check#/ Amount Code INFO By CashemittedDate Permit/ Service Request # Invoice # LENGTH OF LINES ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE 9 "m ta-7 DEPTH rA ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH _ SAN JOAQUIN CONN ft PROPERTY LINE ENVIRONMENTf�L I 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. SIG Application Accepted Final Inspection By_ Character of Soil lt�to��D COMMENTS mac% V/\ TITLE 61 DATE c bPAKTMENTUS ONLY w u Date Area q Employee ID# Date ❑ SPEC AL PERMIT - Approved by 3 Ft: Filksurrp Soil Character: et, PE SC Receive Check#/ Amount Code INFO By CashemittedDate Permit/ Service Request # Invoice # Permit ID# -nZ K O ` -2 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/16