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• PERMIT <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMI-�EXPIRED <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION LJ REPAIR/ADDITION LI ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT 7ZI7M- C --P LCA/ ❑ OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL ERVE: RESIDENCE I7 COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <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 />EMNAMANOV-- TITLE DATE <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Dept <br />COMMENTS <br />of 3 <br />DEPARTMENT USE ONLY <br />Date AreaEmployee ID# — <br />Date 7 SPECT L PERMI -Approved by <br />Pit/Sump Soil Character: <br />PE <br />SEPTIC TANK <br />TYPE/MFG �, �\ . <br />CAPACITY gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />X LEACHING CHAMBERS #OF LINES <br />LENGTH OF LINES\VOft <br />DISTANCE TO NEAREST WELL _ //JD ft <br />FOUNDATION /U ft PROPERTY LINE /;,/&41* ft <br />CJ3 <br />FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />® <br />MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE To NEAREST WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION <br />ft PROPERTY LINE 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 />EMNAMANOV-- TITLE DATE <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Dept <br />COMMENTS <br />of 3 <br />DEPARTMENT USE ONLY <br />Date AreaEmployee ID# — <br />Date 7 SPECT L PERMI -Approved by <br />Pit/Sump Soil Character: <br />PE <br />Sc <br />INFO <br />Received Check/ <br />B a <br />Amount <br />Remitted <br />Date <br />Permit! <br />Service Request # <br />Invoice # Permit ID# <br />gCode <br />yqo <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />