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Li go() si crta OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />LICENSE 0 : C-42 II [ [ C-36 OTHER NUMBER EXPIRATION DATE <br />C ITY/STAT E/ZIP <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X <br />REPAIR/ADDITION <br />OUT-OF-SERVICE SEPTIC SYS <br />NEW INSTALLATION <br />REPLACEMENT <br />TYPE OF WORK: <br />INSTALLATION WILL SERVE: C RESIDENCE <br />NUMBER OF LIVING UNITS: <br />0 COMMERCIAL <br />NUMBER OF BEDROOMS: <br />iffic tiVF CITY/STATE/ZIP <br />PHONE <br />953-76 ASE CALL 209 <br />0 PAY ENT <br />RECEIVED <br />Jth 5 2021 <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 CAL 209) 953-7697 FOR MISR noNs EXPIRES 1 YEAR FROM DATE ISSUED <br />lei /Zit, <br />CROSS STREET <br />OWNER NAME <br />0 PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />ENGINEER DESIGNED <br />DESTRUCTION <br />OTI-IFR <br />NUMBER OF EMPLOYEES: <br />JOB ADDRESS F"-}kj' S I 0 <br />2- (0,Ve <br />ii 2_1 Al Ilk e: <br />0 <br />0 <br />0 <br />SEPTIC TANK <br />GREASE TRAP <br />LIFT STATION <br />TYPE/MFG CAPACITY <br />TYPE/MFG CAPACITY <br />DISTANCE TO NEAREST: <br />SIZE TYPE <br />WELL ft FOUNDATION <br />OF PUMP 0 PKG TX PLANT CI <br />0 LEACH LINES LEACHING CHAMBERS <br />DISTANCE TO NEAREST <br /># OF LINES <br />WELL ft FOUNDATION <br />0 FILTER BED WIDTH ft LENGTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />0 MOUNDED WIDTH ft LENGTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />SUMPS WIDTH ft LENGTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />0 DISPOSAL PONDS WIDTH ft LENGTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />0 SEEPAGE PITS NUMBER WIDTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION <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 />48 HOUR ADVANCE NOTICE REQUIRED FOR INSPEC IONS - P <br /> TITLE DATE <br />MINIM <br />SIGNED <br />ENJIRcbNMEHTA_ <br />1EALf11 EPARTMENT <br />EP <br />Application Accepted By ." Date (Area 77 .2 Employee ID# #44 r, <br />Final Inspection By ".(e grEPP 11°'111,1111ge. ate L] SPECIAL ERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump il Character: <br />6 (2t}'y 0-)WC-E COMMENTS <br />PE <br />Code <br />SC <br />INFO <br />R ce'ved Check# <br />as <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Permit ID# <br />1-r2-20 0 ?5 1 5 -2 --7 1•21 -Skoos.schiPS <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 42-01 <br />4/14/18 <br />UN COUNTY sAN JQA <br />RTMENT USE 0 LY <br />APN <br />ft, al el M614 C <br />PARCEL SEE <br />PHONECZ -f75 o 74(141) <br />2-3 SS3111303V 311S gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LENGTH OF LINES ft <br />ft PROPERTY LINE ft <br />DEPTH ft <br />ft PROPERTY LINE ft <br />DEPTH ft <br />ft PROPERTY LINE ft <br /> <br />DEPTH ft <br />ft PROPERTY LINE ft <br /> <br />DEPTH ft <br />ft PROPERTY LINE ft <br /> <br />ft DEPTH ft <br />ft PROPERTY LINE ft