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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-KEFUNDABLLJE PERMIT C GALL - U9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE] <br />JOB ADDRESS / �'� f�S �" \ty�� �f (CITY/ZIP -� CQi � 0,(\ <br />CROSS STREET r� � �� C R.i� \`\��� APN `( �' V1100 7 9 PARCEL SIZE /T <br />OWNER NAME % `�'1 J PHONE <br />OWNER ADDRESS / a J ' a CITY/STATE/ZIP <br />CONTRACTOR�j ��� '`��r�• G o�� PHONE <br />% <br />CONTRACTOR ADDRESS C... nw' �1 �[�� CITY/STATE/ZIP L il ( :.�[��)`� <br />LICENSE 11❑C-42 11❑C-36 OTHER NUMBEREXPIRATION DATE/3 <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 j1_5hy ) I Vie ❑ ENGINEER DESIGNED /ALTER ATIV <br />❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM X DESTRUCTION It G <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 />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />CAPACITY <br />CAPACITY <br />ft FOUNDATION <br />❑ PKG TX PLANT <br />7 <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />❑ LEACHING CHAMBERS <br />Amount <br />Remitted <br />Permit/ <br />at Service ue t # Invoice # <br /># OF LINES <br />as i <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />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 />SIGNED <br />DATE 3 — \ R t ZO Zv <br />DEPARTMENTJJSEONLY n <br />Application Accepted By Date 3 % Area ; �l Employee ID# <br />Final Inspection By Date 1'L PcP 9- 2JD2__LD SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS DPS}r, C}{on b� CiAJ& -1m: ScO;( -til,,ok R,-,rh1,10i0 4-0 bf [OnYl±:(:'C' 7b S ret ,c <br />1-7 <br />ofb�;fhr-oz)m +V aFP/ sfpL'_ rC�ti�. <br />PE <br />Code <br />SC Received <br />INFO B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Permit/ <br />at Service ue t # Invoice # <br />Permit ID# <br />as i <br />ods <br />' <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />