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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-KEFUNDABLE PERMIT UALL <br />JOB ADDRESS /I/O 3 <br />CROSS STREET Lp✓J'/�� 'f-���5 <br />OWNER NAME <br />`JS.f-/0`J/ FOR 1NSPtC110NS CXF'IKtb l TEAK 1 -HUM LOA It ISSUt <br />CITY/ZIP <br />APN J0 I I 0 I PARCEL SIZE <br />PHONE <br />OWNER ADDRESS //S t y IM f // CITY/STATE/ZIP <br />CONTRACTOR z/C' _nz 1 TAU PHONE <br />CONTRACTOR ADDRESS Cif/%'' I� // /I7/ `� CITY/STATE/ZIP <br />LICENSE ❑� /-42 ❑I C-36 OTHER NUMBER �� %C� 2 EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: <br />❑ PERC TEST # BUILDING PERMIT # <br />Coordinates X Y <br />LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION <br />ED/ALTERNATIVE <br />"le- REPLACEMENT /," " ❑ OUT -OF -SERVICE SEPTIC SYSTEM 'x DESTRUCTION �C ►� �� <br />INSTALLATION WILL SERVE: X- RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: If NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG <br />CAPACITY /,-;'G(j <br />gal # OF COMPARTMENTS^r <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />WELL <br />DISTANCE TO NEAREST: WELL—/'- <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />JR <br />LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES / <br />LENGTH OF LINES ft <br />ft <br />Date <br />Permit/ <br />Service Request # <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE / / ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />SUMPS <br />WIDTH y <br />ft LENGTH <br />I <br />z� ft <br />s <br />DEPTH R ft <br />DISTANCE TO NEAREST <br />WELL J'6 <br />ft FOUNDATION <br />7 <br />ft PROPERTY LINE 35 � ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />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 />SIGNED <br />TITLE <br />DATE v�Z/ <br />DEPARTMENT US -E ONLY <br />Application Accepted By �— - Date 7/J <� Area j �f Employee ID# )� <br />Final Inspection By ts'�I& Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS F�� I� 1 <br />�$y.�i-I�in1' C�C����'i hL 1�'<.•(_� 1�7'leS J' <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />`j� 10 <br />/►s <br />3o 0 <br />3 I <br />I <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />