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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) <br />CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE <br />r <br />JOB ADDRESS ©(��0 <br />G(� <br />O ICU(/ <br />CIJ,�% 17l/ P, a3 <br />Crry/ZIP L O U <br />y4+ <br />CROSS STREET <br />APN <br />Q <br />/JI �' ] . ]( <br />PARCEL SIZE <br />OWNER NAME yaWe-z— <br />WIDTH <br />ft LENGTH <br />PH.NE(&q)321 - /3 <br />OWNER ADDRESS De <br />TO Kaff <br />LOl0I(u lZd— <br />CTYISTATEIZIP lri4 Z <br />CONTRACTOR V rJ,i`r <br />❑ <br />MOUNDED <br />PHONE <br />CONTRACTOR ADDRESS <br />ft DEPTH ft <br />CITY/STATE/ZIP <br />LICENSE ❑ C-42 ❑ C-36 OTHER <br />WELL <br />NUMBER <br />EXPIRATION DATE <br />D <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # i 90310'VLLAND USE APPLICATION # <br />TYPE OF WORK: 10 NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL 2 ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: J NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG L Ar1) CAPACITY n gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG ^ CAPACITY /� `7 a gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINEft <br />❑ LIFT STATION SIZE TYPE OF PUMP 13 PKGTXPLANT O SAND OIL SEPARATOR (ENCLOSE <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 />V. <br />Application Accepted By =� Date L e Area � Employee ID# r 1�i�i �i (5) <br />Final Inspection By �t Date W tl�'SPECIAL PERMIT -Approved by <br />Character of Soil to Depthlbf 3 Ft: PitlSump Soil Character: <br />`Arncru'm <br />LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES • Uf LENGTH OF LINES _ ft <br />DISTANCE TO NEAREST <br />//�, A <br />WELL 2-56) <br />ft FOUNDATION 13ft PROPERTY LINE C �7 <br />- ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />Dat Permit/ <br />Invoice # Permit ID# <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <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 />❑ <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 />❑ <br />DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NE REST <br />WELL <br />ft(�F?O ATIOeN ft PROPERTY LINE ft <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />5(0 a ;(i t DEPTH lz� -5 � ft <br />DISTANCE TO NEAREST <br />WELL T b <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 AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />V. <br />Application Accepted By =� Date L e Area � Employee ID# r 1�i�i �i (5) <br />Final Inspection By �t Date W tl�'SPECIAL PERMIT -Approved by <br />Character of Soil to Depthlbf 3 Ft: PitlSump Soil Character: <br />`Arncru'm <br />'Pw 't per avin <br />or: - SrzI�J tc111� fa ?�Dy <br />"nS wn Y-70 C L <br />5�,d <br />iC Received <br />heck# Amount <br />Dat Permit/ <br />Invoice # Permit ID# <br />RA <br />Fo By <br />Remitted <br />Service Reauest # <br />42-01 A , 0 O a t b WAS-rEW`7AfER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />