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Is <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-KEFUNDABLE PERMIT <br />JOB ADDRESS <br />(;ALL <br />ZU9 953-7697 FOR INSPECTIONS 1L LX-P/I�R^ESS 'I YEAR FROM UATE ISSUEI <br />xp/ CITY/ZIP <br />CROSSSTREET�//lJ1� )�,/?/�/ / APIN (� b `t'yU� PARCEL SIZE <br />/( <br />OWNER NAME _G/; f//j�� 6,14 47 �j��� PHONE �( (JG] 6 (/�) - 6, <br />OWNER ADDRESS , C'1� B ,O CITY/STATE/ZIP / /�� / J <br />CONTRACTOR �% fir' ,ft ,%L�� J /% t /�y ei SL� PHONE II PI 'q � z F [7 `T `? <br />CONTRACTOR ADDRESS /- � � //t/y r /J CITY/STATEIZIP / / .�iJ, <br />110C-36LICENSE ❑C-42 ❑C-36 OTHER NUMBER. 0 f 0 EXPIRATION DATE 2 -1% !� V <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION _e REPAIR/ADDITION ❑ ENGINEER DESIGNED <br />TERNATIVE <br />❑ REPLACEMENT b OUT -OF -SERVICE SEPTIC SYSTEM 4e DESTRUCTION %/ 444LZ <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG / - L <br />CAPACITY 2�5r Zj <br />gal <br /># OF COMPARTMENTS "2— <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal <br /># OF COMPARTMENTS <br />DISTANCE TO NEAREST WELL <br />DISTANCE TO NEAREST: WELL ft <br />FOUNDATION <br />ft <br />PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP ❑ <br />PKG TX PLANT ❑ SAND OIL <br />SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES ❑ LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ FILTER BED WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />C% <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <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 <br />REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINIMUM 48 HOUR 4DV E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED �� TITLE e �/4!�l! DATE <br />DEPARTMENT USE ONLY Ql% <br />Application Accepted By <br />Datef <br />g Area ` ! Employee ID# <br />Date �¢�?�G2� ❑ SPECIAL PERMIT -Approved by <br />Final Inspection By <br />Character of Soil to Depth of 3 Ft: pitlSump Soil Character: <br />COMMENTS Old n /4 Ccs cf au 1(tz UTAA .1411.E /2a 22 <br />PE j1NF0 <br />Code <br />Received <br />B <br />_ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permitl <br />Service Request # <br />Invoice # <br />Permit ID# <br />111, <br />26 <br />3 <br />42 <br />' S ZI <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />42-01 <br />4/14/18 <br />