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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 CALL (ZO,9) 953-/b9/ FOR INSPECTIONS��f(L�� ���' CXPIKt5 I T tAK I-KUM UA I t IJJUtI <br />JOB ADDRESS /� /_ • CITY/ZIP f'(•olmlY%� <br />CROSS STREET L milli �'r— APN < l zr� rG PARCEL SIZE ' <br />OWNER NAME Do YI /— I`{Gi J PHONE <br />OWNER ADDRESS CITY/STATE/ZIP <br />CONTRACTOR ►1 If <br />�jVLr.�( l vy ` �e/ , j�- PHONE 20 <br />CONTRACTOR ADDRESS / G (�Zr"' ' " I1 /`'(/�Q✓` CITY/STATE/ZIPL <br />LICENSE [1) (42 [IOC -36 OTHER NUMBER '-I J EXPIRATION DATE — 1 <br />WATER TABLE DEPTH: <br />ft <br />GEOGRAPHICAL INFORTIO oordina es X Y <br />Check#/ <br />Cash <br />❑ PERC TEST # <br />BUILDING PERMIT #PIAND USE APPLICATION # <br />Permit/ <br />Service Request # <br />TYPE OF WORK: <br />NEW INSTALLATION <br />❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />Cl <br />REPLACEMENT <br />J OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION <br />2 <br />INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: , <br />NUMBER OF EMPLOYEES: <br />NUMBER OF BEDROOMS: �// <br />SEPTIC TANK <br />TYPE/MFG C <br />)j <br />f (. CAPACITY d0II gal # OF COMPARTMENTS <br />l <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />r � � <br />SO /O ft PROPERTY LINE <br />ft <br />DISTANCE TO NEAREST: <br />WELL / y T- ft FOUNDATION .?S <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES <br />ft <br />X <br />DISTANCE TO NEAREST <br />WELL 50 / ft FOUNDATION o;) 6 ft PROPERTY LINE 5" <br />ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE <br />WIDTH ft DEPTH �S <br />ft <br />ft <br />SEEPAGE PITS <br />NUMBER <br />DISTANCE T EAREST <br />r� <br />WELL—/5-0 f �— ft FOUNDATION O 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 />MINIMUM 48 HOUR ADVANCE <br />NQTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7699 <br />SIGNED <br />, <br />TITLE 1' C!C r DATE/—,M" <br />Application Accepted By <br />Final Inspection By <br />� <br />Character of S3*IDepth of 3 <br />COMMENT4 S6A <br />DEPARTMENT USE OJVLY <br />Date i Z4.fea <br />7: Date ZlLllt Z Z ❑ SP <br />Pit/Sump Soil Charactte <br />,n -A ;" I') ti1-e rt) --1�' r -0 <br />n.,. _Kr).til— rf l— — 1 1,1Po'2y <br />Employee ID# <br />PERMIT -Approved by <br />0717173"Nlffi <br />�r <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />�t <br />L <br />J <br />2 <br />S o0gLA-4z <br />42-01 <br />4/14/18 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />T <br />