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44 . , <br />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 <br />JOB ADDRESS G c f71 CY 0 <br />CITY/ZIP <br />CROSS STREET % �n APN PARCEL SIZE <br />OWNER NAME (. 4 al /�/�/ 6se PHONE <br />OWNER ADDRESS` 00 CITY/STATE/ZIP 7� F7 <br />CONTRACTOR ? %C / ` L ` PHONE db c?� �Y � J V 2 Js <br />CONTRACTOR ADDRESS .374a r l"1 fk r CITY/STATE/ZIP <br />jf �� . /EXPIRATION DATE 9 - 3/ r� , <br />LICENSE ❑Ij((;-42 ❑L7C-36 OTHER NUMBER <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION #_ <br />TYPE OF WORK: 0 NEW INSTALLATION REPAIR/ADDITION CI ENGINEER DE: <br />fj REPLACEMENT IJ OUT -OF -SERVICE SEPTIC SYSTEM L.I DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: ( NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />1'I <br />TERNATIVE <br />Application Accepted By - <br />Final Inspection By_z <br />Character of Soil to Depth <br />COMMENTS ,Q44 -r -A <br />RTM <br />Date <br />Date <br />r. <br />7 Area <br />r ❑ SPECIAL <br />Pit/Sump Soil Character: <br />Employee ID# <br />RMIT -Approved by <br />PE <br />Sc <br />Received <br />heck#/ <br />❑ <br />SEPTIC TANK <br />TYPE/MFG 151),&6 V1 q CAPACITY <br />gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP <br />TYPE/MFG CAPACITY <br />gal # OF COMPARTMENTS <br />ash <br />Remitted <br />DISTANCE TO NEAREST: WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR(E,NCLL�OOSED SYSTEM) <br />z C� <br />L 'I I `!, <br />� <br />LEACH LINES <br />[l LEACHING CHAMBERS G�(� / Y v # OF LINES <br />ft <br />LENGTH OF LINESV <br />PO / <br />/O , ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />❑ <br />FILTER BED <br />WIDTH ft L NGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />SUMPS <br />`, 1 <br />WIDTH T ft LENGTH �� ) ft <br />DEPTH av Awz ft <br />/Xr <br />DISTANCE TO NEAREST WELLJM' , ft FOUNDATION d0 A <br />ft PROPERTY LINE - ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH ft LENGTH L C ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft 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 />MINIMUM 48 HOUR ADVANCE NOLTWE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED ��`— <br />TITLE <br />DATE DATE 3 <br />Application Accepted By - <br />Final Inspection By_z <br />Character of Soil to Depth <br />COMMENTS ,Q44 -r -A <br />RTM <br />Date <br />Date <br />r. <br />7 Area <br />r ❑ SPECIAL <br />Pit/Sump Soil Character: <br />Employee ID# <br />RMIT -Approved by <br />PE <br />Sc <br />Received <br />heck#/ <br />Amount <br />Date <br />Permit/ <br />Invoice # <br />ermit ID# <br />Code <br />INFO <br />By <br />ash <br />Remitted <br />Service Request # <br />z C� <br />Il <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />