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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-REFUNDABLE PERMIT /� AY'(:ALL ZU9 9b3-/697 FOR INSPECTIONS . EXPIRES I YEAR FROM DATE ISSUEI <br />JOB ADDRESS ZZW <br />Z- <br />_I . g Z•GC-jT r2- CITY2IP Lot>i 9 S ;t --F-2— Q� <br />CROSS STREET Div � C� APN O 2-5-- ( Le 0 _ 4 LP PARCEL SIZE t' �' ` `• <br />OWNER NAME Z A C' C 1—Lk S PHONE ( S'�`1> 303 - C) 9 9 <br />OWNER ADDRESS 44 1 l ��C, r- EYzNE�T STS CITY/STATE21P J1S&Q A CA 932 _T-7 <br />CONTRACTOR 1-1UE O�C� �.�LdE-rJV�j2DrVl4�1 E•►�%'j `' PHONE 31P11-0-317 <br />CONTRACTOR ADDRESS qV-1 IAJ- 0AW_ -q-F. CITY/STATE/ZIP L_0*D ( <br />LICENSE ❑CIC -42 DOC -36 OTHER (2 e& NUMBER y(�( EXPIRATION DATE 1+--3o-2z <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br />❑ REPLACEMENT U OUT -OF -SERVICE SEPTIC SYSTEM 0 DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />0 DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />I] LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE To NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION 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 <br />AND RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINIMUM <br />R AaVANCENOTICE <br />/RED FOR MPECTIONS- PLEASE CALL 2 7 <br />SIGNED <br />TITLE Au -1• m 6/i • DATE z — I — 2 ( <br />DEPARTMENT S ONLYS <br />Application Accepted By �- L Date � Area Employee ID# A <br />Final Inspection By Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />PE SC Receiv d Check#/ Amount Date PermiU Invoice # Permit ID# <br />Code INFO Cash Remitted I I Service Re uest# <br />as 19 51� 3 12-1 220 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />TY <br />NT <br />