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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />tAN 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 ADDRESS1 /y n /2 CC --3e CITY/ZIP 9' 5 Z2CJ <br />CROSSSTREET 6-ra l(� /G1 APN 00-7 27V — y r <br />/ 6 PARCEL SIZE <br />OWNER NAME /" q / 4A_ PHONE <br />OWNER ADDRESS e /� 7 ZE ( 211;1",` /(�2/ C5 CITY/STATE/ZIP / �jL q2 G (� <br />CONTRACTOR �A- /^� 2O k liy�_ PHONE ��� 2/ / <br />CONTRACTOR ADDRESS !i% CITY/STATE/ZIP <br />LICENSE 0❑C-42 11❑C-36 OTHER NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: 1 `v -- (361 <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # / 0BUILDING PERMIT # • Zl `f 7 LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />❑ REPLACEM UT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />tt <br />ATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ElOTHER <br />MBER OF LIVING UNITS: NUMBER OF BEDROOMS: 2 NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS 121 <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 />❑ <br />LEACH LINES <br />TO ft <br />❑ LEACHING CHAMBERS <br /># OF LINES 2- LENGTH OF LINES ft <br /><Pheck#0 <br />as <br />DISTANCE TO NEAREST <br />WELLI C�6 �' ft <br />FOUNDATION�ft PROPERTY LINE 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 <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE NEA <br />—1 WELL FOUNDATION ft PROPERTY LVE_ ft <br />SEEPAGE PITS NUMBER !/ WIDTH ft DEPTH 7i ft <br />9( ir <br />DISTANCE TO NEAREST WELL A ft FOUNDATION J 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 ADVANCE NOTICE E IRED FOR INSPECTIONS - PLEASE CALL 209 53-76997 <br />SIGNED TITLE 01k --e " DATE 32— <br />Application <br />Application Accepted By Date <br />Final Inspection By_�kjI(ISt o [�2i 1 4'>Z Date <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS <br />Area Employee ID#_ <br />_ �� - ❑ SPECIAL PERMIT -Approved by <br />Pit/Sump Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Received <br /><Pheck#0 <br />as <br />Amount <br />Remi ted <br />Date <br />Permit/ <br />Servic a uest # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />T <br />a <br />d <br />d <br />