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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 CALL(209) 953-7697 FOR INSPECTIONS EXP RES 1 YEAR FROM DATE ISSUED <br />Ci <br />JOB ADDRESS QV G 7 J (� C /CITY/ZIP d %'� / �% 16 <br />CROSS STREET /� ^ 1 1 ("� �-+1 �rr y.1A}PN '� I J l� PARCEL SIZES (" I (I O /� t �] <br />OWNER NAME G AN O PO -A � � , / _ � L L PHONE 30q — / ;p r V ` —1 <br />OWNER <br />CITY/STATE/ZIP <br />CONTRACTOR 0 Tc�`[/�^- t PHONE v '� V ? O <br />CONTRACTOR ADDRESS 1&q J + V �� CITY/STATE/ZIP <br />LICENSE ❑OC -42 ❑X-36 OTHER NUMBER !II E;rD EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: 0 NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIV <br />0 REPLACEMENT G OUT -OF -SERVICE SEPTIC SYSTEM X DESTRUCTION ' JLr, <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />CAPACITY <br />CAPACITY <br />ft FOUNDATION <br />❑ PKG TX PLANT <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />Cl LEACHING CHAMBERS <br />Received <br />B <br />hec <br />ash <br /># OF LINES <br />Date <br />DISTANCE TO NEAREST <br />WELL <br />Permit ID# <br />ft <br />FOUNDATION <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />LENGTH OF LINES _ <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <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 />SIGNED <br />Application Accepte <br />Final Inspection ByI( <br />Character of Soil to <br />COMMENTS A <br />vrx livor -c a, r rvrv._j Imo"• <br />TITLE / Y Q� Q �� DATE <br />ISE —ONLY <br />Area r Employee ID# <br />�'Ti ❑ SPECIAL PERMIT -Approved by <br />Pit/Sump Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />hec <br />ash <br />Amount <br />Remitted <br />Date <br />Permitl <br />Service Request # <br />Invoice # <br />Permit ID# <br />q 3d ) <br />0-75- <br />s <br />34Z2 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />:.I <br />