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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 EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS AO V 7 % f) CITY/ZIP J 2J%� ./ SA/�lYCX�C (� <br />CROSS STREET SU�-J�I / <br />LLr� 7_{2 GiC� APN D G-3 Z60 D cJ PARCEL SIZE 3 ILO <br />OWNER NAME 5-2hll /-g:r2i 5 PHONE %1' �fL'! Z? -?C7 <br />OWNER ADDRESS / J CITY/STATE/ZIP <br />CONTRACTOR �r N ben Cl-/ /� PHONE J / <br />CONTRACTOR ADDRESS 327 e E /fix CITY/STATE/ZIP <br />LICENSE [1)t-42[IC-36 OTHER NUMBER 1/5 ?©YS— EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # J5 AND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG �irz CAPACITY %LSU gal # OF COMPARTMENTS_ <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />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 />W LEACH LINES LEACHING CHAMBERS <br />DISTANCE TO NEAREST <br />FILTER BED WIDTH <br />DISTANCE TO NEAREST <br />MOUNDED WIDTH <br />DISTANCE TO NEAREST <br />SUMPS WIDTH <br />DISTANCE TO NEAREST <br />DISPOSAL PONDS WIDTH <br />DISTANCE TO NEAREST <br />IL SEEPAGE PITS NUMBER_ 3 <br />DISTANCE TO NEAREST <br /># OF LINES 3 <br />WELL <br />SC <br />INFO <br />ft FOUNDATION <br />Check#/ Amount <br />as Remitted <br />ft <br />LENGTH <br />Permit ID# <br />ft <br />WELL <br />ft FOUNDATION <br />ft <br />LENGTH <br />ft <br />WELL <br />ft FOUNDATION <br />ft <br />LENGTH <br />ft <br />WELL <br />ft FOUNDATION <br />ft <br />LENGTH <br />ft <br />WELL <br />ft FOUNDATION <br />_ <br />WIDTH <br />L,y <br />ft <br />WELL <br />ft FOUNDATION <br />LENGTH OF LINES ft <br />ft PROPERTY LINE ft <br />DEPTH ft <br />ft PROPERTY LINE ft <br />DEPTH ft <br />ft PROPERTY LINE ft <br />DEPTH ft <br />ft PROPERTY LINE ft <br />DEPTH ft <br />ft PROPERTY LINE ft <br />DEPTH d.S ' ft <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 �Jy�' TITLE DATE <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to De of <br />COMENTS r <br />/^ - <br />�l DEPARTMENT USE ONLY EmployeeID# <br />/ Area <br />Date 2 ❑ SPECIAL PERMIT -Approved by <br />Ft: Pit/Sump Soil Character: <br />it A ;�-- <,q <br />PE <br />Code <br />SC <br />INFO <br />Receive <br />B <br />Check#/ Amount <br />as Remitted <br />Date Permit] <br />ince Request # <br />Invoice # <br />Permit ID# <br />(Se <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />r <br />