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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 209 953-7697 FOR INSPECTIONS EXPIRES 'I/YEAR FROM L)ATE ISSUEI <br />JOB ADDRESS O 729 Cbo;�N j /CIITY/ZIP S <br />CROSS STREET C 1"l / '� APN Q gbb(,'J36 PARCEL SIZE <br />OWNER NAME G e a f !�) yl C' C'� 0, (1 VV1 PHONE <br />OWNER ADDRESS CITY/STATE/ZIP <br />CONTRACTOR Ibr �Nh PHONE o C— -�2} �rfJJ^ <br />CONTRACTOR ADDRESS 1`][/J,4�- /P*2 CITY/STATE/ZIP :��- <br />� <br />r� " J <br />/'I' <br />LICENSE 11K-42 1111C -36C-36 OTHER NUMBER EXPIRATION DATE //�3 <br />/1 - <br />WATER TABLE DEPTH: -" Q ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: 0 NEW INSTALLATION1 REPAIR/ADDITION I_1 ENGINEER DESIGNED /ALTERNATIVE <br />❑ REPLACEMENT T L' 11 7 OUT -OF -SERVICE SEPTIC SYSTEM N DESTRUCTION tt811 k <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 1. NUMBER OF EMPLOYEES: <br />xSEPTIC TANK <br />TYPE/MFG � Aif1Fc l/- Y(. <br />CAPACITY OQ <br />gal <br />#OFCOMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal <br /># OF COMPARTMENTS <br />WELL 1 <br />DISTANCE TO NEAREST: WELL b11 C <br />ft FOUNDATIONf ft <br />❑ <br />PROPERTY LINE d 7b ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />qp <br />LEACH LINES <br />❑ LEACHING CHAMBERS <br />Check#/ Amount Date <br />sh Remitted <br /># OF LINES <br />g310 <br />LENGTH OF LINES S� / ft <br />2 2 300 <br />DISTANCE TO NEAREST <br />WELL 1 <br />ft <br />FOUNDATION 2eft 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 <br />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 <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />SEEPAGE PITS <br />NUMBER I <br />WIDTH <br />11 <br />29 <br />ft DEPTH C2ft <br />DISTANCE TO NEAREST <br />WELL F4Wi6 ft <br />FOUNDATION <br />CJ ' <br />ft PROPERTY LINE O f 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 />DEPARTMENT S ONLY <br />Application Accepted By �L�L' Date /5" 7 Area % —/ Employee ID#� <br />Final Inspection By Date ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: oitjq,,mRo.l Character: <br />COMMENTS F" Sy5}Pttit. teanclill <br />PE <br />Code <br />SC <br />INFO <br />Received <br />AB <br />Check#/ Amount Date <br />sh Remitted <br />Permit/ Invoice # Permit ID# <br />Service Re uest # <br />g310 <br />2 2 300 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4114/18 <br />