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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-KEFUNDABLE PERMIT / r GALL (ZUY) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE <br />!Z <br />JOB ADDRESS '� I S CIS 7 1 1`� �D hd a n l e r a ca. CITY/ZIP 33 Z <br />CROSS STREET((�� APN Z Cj I 10 00 PARCEL SIZE <br />OWNER NAME C.0-cil CA n JP (24 PHONE <br />OWNER ADDRESS '�/ Q� )S �� f�f �J� CITY/STATE/ZIP Maya 4 c a C 12 <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS <br />LICENSE ❑' C-42 ❑ C-36 OTHER <br />CITY/STATE/ZIP <br />NUMBER EXPIRATION <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION <br />❑ PERC TEST # BUILDING PERMIT # K - <br />TYPE OF WORK: I NEW INSTALLATION REP IS�R/A^^DI <br />REPLACEMENT OUT -U / <br />Coordinates X Y <br />LAND USE APPLICATION ## <br />IN ENGINEER DESIGNED / <br />E SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL J ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: !/lam NUMBER OF EMPLOYEES: <br />TERNATIVE <br />❑ SEPTIC TANK <br />TYPE/MFG <br />Received <br />B <br />CAPACITY gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />Cr <br />CAPACITY gal # OF COMPARTMENTS <br />Permit ID# <br />DISTANCE TO NEAREST: <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ✓ ft <br />t <br />DISTANCE TO NEAREST <br />WELL / ft <br />_ <br />FOUNDATION ft PROPERTY LINE g, ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />��—ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />` �Q SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ? ft <br />/ \ <br />DISTANCE TO NEAREST <br />WELL ft <br />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 AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED <br />TITLE DATE �� O <br />DEPARTMENT USE ONLY /I <br />Application Accepted By Date Area Employee ID# <br />Final Inspection By Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to De th of 3 Ft: Pit/Sump Soil Character: <br />COMMENTSA��l��q � ,r�-�. <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cas4 <br />Amount <br />Remitted_Date <br />Permit/ <br />SeAvice Request # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />T <br />