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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERM JOB ADDRESS CROSS STREET OWNER N (:ALL C. FOR INSPECTIONS tXP[KtS l T LAK FKUM UAI It I55Utl S�'• CITY/ZIP cJ0 APIN CJ yJ / j PARCEL SIZE PHONE OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR �%O/Ca'LT/^ (� ✓J�'� , je- PHONE j— � V`�3p/ CONTRACTOR ADDRESS / / �yJ✓J✓1 L `� c/ i+ CITY/STATE/ZIP LICENSE ❑CIC -42 ❑LIC -36 OTHER NUMBER J / 1� EXPIRATION DATE 3J i WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: 11 NEW INSTALLATION a REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE C! REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG CAPACITY CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) E] LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES 7// O ft Amount Date DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE L% D ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft Service Request # DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft F 'IQ(1/ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER 2 WIDTH _-S� i^ ft DEPTH 2 ft DISTANCE TO NEAREST WELL ," '� ft / FOUNDATION (p 6) ft PROPERTY LINE ✓ ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. SIGNED W (// P,- I Application Accepted By Final Inspection By Character of Soil to Dept COMENTS VR //YJ rCl/,r IIVIYJ - rLLMJL I,HLL 1 GV.7/ .7JJ-/ VJ/ TITLE c _ ,.✓�v9c l-�� DATE�Z� / TO DEPARTMENT USE ONLY / Date l Q Area L Date t4 c k ❑ SPE Pit/Sump Soil haracter: Y- Z� Employee ID# PERMIT -Approved by L 107 PE SC Received ec Amount Date Permit/ Invoice # rmit ID Code INFO By ash Remitted Service Request # In I C F 'IQ(1/ J "'L/'H p '",hF'v--IVn, 42-01 ONSITE WASTEWATER TRTMNT S�MIT 4/14/18 NT T