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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-KEFUNDA�BB�L�E <br />JOB ADDRESS 10le <br />CROSS STREET A u S -1 H r -D • .. r APN �Tl ' 070 t b PARCEL SIZES �2. O p <br />OWNER NAME D V LAt4 d op k ii,, PHONE 2-0 q ' <br />OWNER ADDRESS I' �1 CITY/STATE/ZIPP Y t.�� co <br />CONTRACTOR C ui' PHONE <br />CONTRACTOR ADDRESS �? U _ Y) x Jd l 1 -b/.4 CA CITY/STATE/ZIP I u xLO cKt eA 9538/ <br />LICENSE ElC-42U _ C-36 OTHER R I� E NUMBER J`I EXPIRATION DATE G L • LZ y <br />D <br />WAXER <br />TABLE DEPTH: <br />It GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />PERC TEST # <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEW INSTALLATION <br />REPAIR/ADDITION <br />_ ENGINEER DESIGNED /ALTERNATIVE <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />_. REPLACEMENT _ <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />_ DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />O <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 />DEPTH ft <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />It PROPERTY LINE ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />O LEACH LINES <br />C LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />It <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH it <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />It 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 />PA Y Wf <br />'NT <br />Area 1 % Employee ID# <br />Q SPECIAL PERMIT - Approved by <br />Invoice # I Permit ID# <br />Lam► I���iTt�[/1.i����Gi:{T.Li�F,��/�f1�f�T'1��'�lf�zt�%�11'�� <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4114/18 <br />