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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 />NON-REFUNDABLE PERMIT <br />TYPE/MFG <br />CALL 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUE[ <br />JOB ADDRESS <br />'�TC� <br />; X209 <br />y� <br />�4 �cj \ � AO ct_-y .r r, CITY/ P � �,-,1.. <br />� (/ <br />�gySD <br />CROSS STREET 1 R r i, <br />��- <br />,-��/ <br />1 5� 1r APN O 0-705D <br />PARCEL SIZE <br />OWNER NAME ,I <br />o �(� <br />U r TI Ir, `� <br />PHONE_ %j Y �p / <br />OWNER ADDRESS Pd -P-0><'40 <br />❑ PKG TX PLANT <br />CITY/STATE/ZIP ///�� �1 <br />a <br />CONTRACTOR ���+ <br />PHONE <br /># of LINES <br />CONTRACTOR ADDRESS <br />ft <br />CITY/STATE/ZIP <br />DISTANCE TO NEAREST WELL <br />LICENSE 117C-42 ❑LIC -36 <br />OTHER <br />NUMBER EXPIRATION DATE <br />❑ FILTER BED <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 IENGINEER DESIGNED /AII.TERNPTIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM y,( DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL C OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />Permit ID# <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />i LEACHING CHAMBERS <br /># of LINES <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />It <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE To NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />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 <br />COUNTY. <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED <br />FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED <br />" <br />TITLE <br />Ours l DATE <br />ti <br />o <br />4_7 <br />N p <br />DEPARTMENT USE ONLY <br />Application Accepted By L G Date /a od Jdu Area Employee ID# <br />Final Inspection Byt �•� c�Styi +�(,i 1 Date�� I f'% C SPECIAL PERMIT -Approved by <br />Character of Soil toDepth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS HoLSP -Fo be dProohJler) <br />�Q <br />PE <br />Code <br />SC <br />INFO <br />Received Check#/ Amount Date Permit/ <br />B Cash Remitted Service Request # <br />Invoice # <br />Permit ID# <br />'lad I <br />D75- <br />-�)Sa 12'2.2p 0 S <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 II -752_ % �S j <br />