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r 10 <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 <br />CALL <br />209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUE <br />JOB ADDRESS <br />LENGTH OF LINES Z` ft <br />CITY/ZIP 1Z <br />S <br />CROSS STREET j✓11 1'1� �� <br />ft <br />1I11 <br />APN N <br />PARCEL SIZE <br />Ej I . 3 s, <br />�-C <br />OWNER NAME �/ / �� �� C <br />�Y�( <br />�`� <br />PHONE �r%�' !3 O / / <br />/ /� <br />CITY/STATE/ZIP <br />DEPTH ft <br />/'��<<�'-fI <br />OWNER ADDRESS`( <br />I C' <br />1� <br />ft <br />CONTRACTOR/vel �� 1' <br />PHONE <br />❑ MOUNDED <br />CONTRACTOR ADDRESS <br />LENGTH <br />CITY/STATE/ZIP <br />LICENSE LL IC -42 ❑1 IC -36 OTHER <br />DEPTH ft <br />NUMBER EXPIRATION DATE <br />DISTANCE TO NEAREST WELL <br />9 <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: C ordi ates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATIONIRE AIR/ADDITION El ENGINEER DESIGNED /ALT NATIVE <br />f REPLACEMENT II OUT -OF -SERVICE SEPTIC SYSTEM X� DESTRUCTION <br />INSTALLATION WILL SERVE: C RESIDENCE C COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ) NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG CITY /,� C1 C gal # OF CdMOR4'MWTS ' <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑. LEACH LINES <br />LEACHING CHAMBERS <br />e Amount Permit/ <br />Cash, emitted Date Service Request # <br />Invoice # <br />#OF LINES <br />LENGTH OF LINES Z` ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <br />WIDTH ft <br />LENGTH <br />ft <br />DEPTH It <br />DISTANCE TO NEAREST WELL <br />FOUNDATION <br />ft PROPERTY LINE ft <br />SEEPAGE PITS <br />NUMBER WIDTH <br />; �ft <br />y / <br />J <br />ft <br />DEPTH `g 7 ft <br />DISTANCE TO NEAREST WELL <br />ft <br />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 />Character of Soil to Depth of 3 Ft: PIVSUmp 5011 Character: <br />COMMENTE(Q)/'1 I `-Owri�F;1 Cejw)e ;, 4, ,/wow ir,�r�G'T� -11 P,, is ;er-4)(ed ZD s>�" l6wecrs" r"S� C4'-•�V', <br />S -t U. �f fPc� : �l�i1it'.• f :� R 1 fi/L 2 (� I'�i�ii7 A) ' 6TX7i�X— [ 6 6�A /�/ril/i� <br />LA <br />C+7 <br />a <br />0 <br />d <br />ren <br />M <br />PE <br />Code <br />SC eceive <br />INFO B <br />e Amount Permit/ <br />Cash, emitted Date Service Request # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />