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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 />IVUN-Mitt-UNUAIiLt rtKMI I <br />JOB ADDRESS <br />CROSS STREET A*11 /// <br />OWNER NAM <br />,/� CITY/ZIP /���/�� :� & ZL /7 <br />APN t2! / ( /'?O PARCEL SIZE -J��5i/j <br />PHONE 7RCg�' t /� <br />OWNER ADDRESS �„/1 CITY/STATE/ZIP <br />CONTRACTORT PHONE_ <br />CITY/STATE/ZIP <br />LICENSE ❑❑C-42 1111C-36 OTHERNUMBER � n EXPIRATION DATE /,f-' <br />CONTRACTOR ADDRESS <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />D REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />CAPACITY <br />CAPACITY <br />ft FOUNDATION <br />❑ PKG TX PLANT <br />i <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />❑ LEACHING CHAMBERS <br />Received <br />B <br /># OF LINES <br />o <br />LENGTH OF LINES ft <br />Ju 21 U <br />1 <br />DISTANCE TO NEAREST <br />WELL OJ <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH fl <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTYLINEft <br />SUMPS <br />WIDTHy <br />ft LENGTH <br />` 61 <br />ft <br />DEPTH 4 Y�, ft <br />DISTANCE TO NEAREST <br />WELL' t:j:O/nt ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <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 />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft <br />DEPTH ft <br />DISTANCE To NEAREST <br />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 />SIGNED <br />VIl 1/11"7!-[-1+//V/Y"7 - r-L[-/i"7C 1."HLLLV.Y YaJ-fow <br />TITLE eff � DATE - 7 <br />Ah EPARTMENT USE ONLY /L� <br />Application Accepted By Date Area Employee I D#1� <br />Final Inspection B Date �O 11S'('�,` ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS tgj;. 2L r-,A&If <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ Amount ate Permit/ Invoice # Permit ID# <br />Cas Remitted Service Re vest # <br />o <br />Ju 21 U <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />