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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 yJ q GALL 109 953-7�6J97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS L' /"/�D� llYlcy ,�<��'t� CITY/ZIP jcx�c- <br />CROSS STREET %��yu�� 5s'I� AP L/ J V / PARCEL SIZE • c� <br />OWNER NAME ��ii'/2�/ �� �clyYi7 PHONE <br />OWNER ADDRESS/ .�+`/��?� / fJ CITY/STATE/ZIP <br />CONTRACTOR G e y�fJCiJ �/✓� � f/c� PHONE �� �' S OZ 2 <br />CONTRACTOR ADDRESS �/ L�L ./L'••liJ1ZGO //_///C %�iCCITY/STATE/ZIP <br />LICENSE FYk--42 ❑LIC -36 OTHER <br />NUMBER L/S��I �S EXPIRATION <br />WATER TABLE DEPTH: J J ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: Ci NEW INSTALLATION 2�- REPAIR/ADDITION I l ENGINEER DESIGNED /ALTERNATIVE <br />CI REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: g RESIDENCE ❑ COMMERCIAL Fl + A ❑ OTHER <br />L� �+�:rCt./ <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 1 I I F. r. ,_ , i pT NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFGXrj�� <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />ft FOUNDATION Zd ft PROPERTY LINE <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />�— LEACH LINES <br />LEACHING CHAMBERS <br /># of LINES LENGTH OF LINES_ <br />ft <br />Permit/ Invoice # <br />Permit ID# <br />DISTANCE TO NEAREST <br />WELL 5-0 r <br />ft FOUNDATION Zd ft PROPERTY LINE <br />ZU ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH <br />ft <br />Z D x-300 <br />2--1,79 -72 <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE To <br />WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />SUMPS <br />NEAREST <br />WIDTH /i <br />ft LENGTH <br />ft DEPTH A) <br />ft <br />DISTANCE TO NEAREST <br />WELL /'t3-0 f <br />ft FOUNDATION 60.ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION 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 />DEPARTMENT USeF ONLY <br />Application Accepted By v Date Area Employee ID# <br />Final Inspection By Date LOZz ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />PE <br />SC <br />Received c Amount <br />Date <br />Permit/ Invoice # <br />Permit ID# <br />Code <br />INFO <br />By_ Remitted <br />Service Request # <br />qd) c) <br />its <br />Z D x-300 <br />2--1,79 -72 <br />21 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />T <br />