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.5P's v11 (5 CITY/STATE/ZIP <br />PHONE 3 (.9 9 - t."3 1 s- <br />crryisTATErzip C 9S- 2-40 <br />CONTRACTOR t- 04°C le- elw lico"..) 04 E.-N.17m_ <br />CONTRACTOR ADDRESS L'kte) LA.) • o iecs-• ST. <br />WATER TABLE TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X <br />TYPE OF WORK: <br />PERC TEST # <br />NEW INSTALLATION <br /> REPAIR/ADDMON <br />SYSTEM REPLACEMENT 0 OUT-OF-SERVICE SEPTIC <br />LAND USE APPLICATION # BUILDING PERMIT # <br />o OTHER <br />NUMBER OF EtIPLOYEES: <br />CI COMMERCIAL INSTALLATION WILL SERVE: C RESIDENCE <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />CI MOUNDED WIDTH <br />DISTANCE TO NEAREST <br />SUMPS WIDTH <br />DISTANCE TO NEAREST <br />ID DISPOSAL PONDS WIDTH <br />DISTANCE TO NEAREST <br />SEEPAGE PITS NUMBER <br />DISTANCE TO NEAREST <br />LEACH LINES Li LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />FILTER BED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />ft LENGTH ft DEPTH ft <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />ft LENGTH ft DEPTH ft <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />ft LENGTH ft DEPTH ft <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />WIDTH Ft DEPTH ft <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />SEPTIC TANK TYPE/MFG CAPACITY <br />GREASE TRAP TYPE/MFG CAPACITY <br />DISTANCE TO NEAREST: WELL ft FOUNDATION <br />LIFT STATION SIZE TYPE OF PUMP I PKG TX PLANT <br />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 1 YEAR FROM DATE ISSUED <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />ENGINEER DESIGNED/ALTERNATIVE <br />DESTRUCTION <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 />MINIMUM OUR ADWICE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 <br />SIGNED v 2l rt7 //C-C- TITLE ria-0-3 • 144 644 • DATE q <br /> SEP <br /> PAYMENT <br />RECEIVED <br />1 0 2021 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 42-01 <br />4/14/18 <br />'QUIN COUNTY <br />RONMENTAL <br /> I DEPARTMENT <br />"la <br />EO L 6.4 <br />-ea I Employee ID#_?“:77 <br />Y <br />0 SPECIAL PERMIT - Approved by <br />Pit/Sump Soil Character: <br />e.- <br />SAN A.11 <br /> ENV <br />ARTMENT U <br />Date <br /> -Date <br />Character of Soil to tre/pth of 3 . <br />COMMENTS <br />Application Accepted By <br />Final Inspection By / <br />PE <br />Code <br />SC <br />INFO <br />Received Check#/ <br />Remitted <br />Amount Permit/ <br />° e Service Request # Invoice # Permit ID# <br />LO2 521 <br />4( <br />1 -1I <br />Casb <br />-`1 (2iSROCM1-2.00 <br />KEALTI <br />fl <br />5:5 <br />40 <br />D E <br />JOB ADDRESS 3 ,t, f.2. Cgs/ ER- i2-1) • 0,y/zip I. 0'1\J 91-3 <br />LICENSE 1 .1C-42 LIC-36 OTHER Ct.C, NUMBER 2- I CI EXPIRATION DATE 44 - <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />APN 2_21 - 2-co- PARCEL SIZE 3 - <br />PHONE (D1 9 - ‘-f•I Le <br />EAJTY <br />MoNi C