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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-KEFUNDABLE PERMIT (:HLL (ZU,9) y33 -/6y/ FOR INSPECTIONS tXPIRES 'I YEAR FROM UATE ISSUEI <br />JOB ADDRESS 14o1 CITY/ZIP (%h% i 2 -ft _ <br />CROSS STREET APN J ' PARCEL SIZE O <br />OWNER NAME / PHONE — <br />OWNERADDRESS CITY/STATE/ZIP <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE 11CIC-42 ❑L!C-36 OTHER NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />Amount <br />emitted <br />❑ <br />PERC TEST # <br />Invoice # <br />I <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />❑ NEW INSTALLATION L <br />REPAIR/ADDITION <br />❑ ENGINEER DESIG D IALTERNAT E <br />- V- <br />I. 1 REPLACEMENT LI <br />OUT -OF -SERVICE SEPTIC <br />SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL <br />SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ <br />SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ <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 />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />U <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />1 ' 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 />❑ <br />FILTER GED <br />WIDTH ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />SUMPS <br />WIDTH ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <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 COUNTY. <br />SIGNED <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to DeDth of 3 Ft: <br />VR IIYJ/�LV 1 IVIYJ - rLLf-IJL l,/YLL I LVJ/ J- <br />TITLE DATE y <br />! `C J C"L <br />.D PARTMENTS N Y <br />Date-::z//_S t" I Area Employee IDIt <br />Date d ❑ SPE AL PERMIT - Approved by <br />Pit/SumD Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Receivheck#/ <br />Cas <br />Amount <br />emitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />-q&c � 019 <br />U <br />- V- <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4114/18 <br />Z' <br />M <br />C <br />C <br />