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I <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-KEFUNDABLE PERMIT (:ALL <br />LUy yt)3-/Oy/ FOR INSPECTIONS <br />tXPIRES 'I YEAR FROM DATE ISSUE' <br />JOB ADDRESS sda <br />/�- 6/.(" <br />If CITYYIZIP <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />�I�Z1�� <br />C] <br />�� 0Of g <br />❑ ENGINEER DESIGNED IALTERNA IVE <br />CROSS STREET <br />'/ IG,�n <br />APN / �? <br />PARCEL SIZE O / <br />OWNER NAME /�`Lf <br />!% L� I i /J OO <br />PHONE <br />OWNER ADDRESS <br />✓yn <br />CITY/STATE/ZIP <br />�/fLGZ <br />CONTRACTOR <br />/eJ1 <br />PHONE <br />' <br />` / <br />CAPACITY /� J O <br />O <br />❑ <br />�L� �� �✓ 3�y <br />CONTRACTOR ADDRESS <br />!i 19.2 /Q <br />CITY/STATE/ZIP <br />/iLf �I /'. <br />DISTANCE TO NEAREST: WELL <br />3aEXPIRATION <br />ft PROPERTY LINE ft <br />LICENSE I�UC-42 <br />❑OC -36 OTHER <br />NUMBERy DATE <br />°J s� <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />❑ <br />PERC TEST # <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />❑ NEW INSTALLATION ❑ <br />REPAIRIADDITION <br />❑ ENGINEER DESIGNED IALTERNA IVE <br />❑ REPLACEMENT ❑ <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />,$1 DESTRUCTION Se IL YI <br />INSTALLATION <br />INSTALLATION <br />WILL SERVE: RESIDENCE <br />❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG 4111-14l� V � <br />` / <br />CAPACITY /� J O <br />gal # OF COMPARTMENTS 2 <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft 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 />❑ <br />LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />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 />DEPARTMENT USE ONLY <br />Application Accepted By Z" Date 3 3:��— Area Employee ID# G9Ilk <br />Final Inspection By j Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth 3 Ft: --Pit/Sump Soil Character: <br />•}cy iii e me <br />COMMENTS _ R -e 41'00C k b(P�n� �1 P l �+e"'I Look Le )✓' Se;Yhe <br />e <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />/ Amount <br />Cash Remitted <br />Date Permit/ <br />Service Re uest # <br />Invoice # Permit ID# <br />aQrl <br />l h <br />>> S <br />2 f?oa <br />oI102- Si, 0096 9 <br />42-01 <br />4/14/18 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />