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��]P6y����i%F����i%���:i�:7�_r�►�il�����'6���►�i�J�:7►TiiiI <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOC KTON CA 95205 -(209)468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS !� 3�(-t T,, <br />CITY1zPP <br />P-,� <br />CROSS STREET -t �"/C(%/ <br />/ n <br />/U " <br />../ <br />T— /�(/CI APN �'/DS J� PARCEL SIZE V <br />Y <br />OWNER NAME <br />PHONE <br />OVMER ADDRESS <br />CITY/STATEIZIP <br />SIZE TYPE OF PUMP <br />/' /L <br />CONTRACTOR <br />✓ RHONE <br />WIDTH ft LENGTH It DEPTH <br />!n <br />CONTRACTOR ADDRESS <br />CITYISTATEIZJP <br />LICENSE X/C�z C-36 OTHER <br />NUMBER �s s EXPIRATION DATE—'? —✓/ - I <br />❑ <br />SUMPS <br />WATER TABLE DEPTH: <br />`-' ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # <br />BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAJRIADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT-OF.SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: <br />RESIDENCE COMMERCIAL OTHER <br />INUMBER OF LIVING UNITS: !I <br />NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG ��I S 1 I (� <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />FILTER BED <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE R <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />U PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />Application Accepted By <br />Final Inspection By_�; <br />Character of Soil to Dept <br />COMMENTS/)k- <br />DATE ✓ —��^P� <br />1 Employee ID# <br />PERMIT -Approved by <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />LEACH LINES <br />LEACHING CHAMBERS #OF LINES LENGTHOFLNEs ,?,D.1A'4 /w)� t <br />DISTANCE TO NEAREST WELL' ft FOUNDATION i �' ft PROPERTY LINE `o' <br />ft <br />❑ <br />FILTER BED <br />WIDTH ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH It DEPTH <br />It <br />DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE <br />ft <br />❑ <br />SUMPS <br />WIDTH ft LENGTH It DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH R DEPTH <br />R <br />(� <br />SEEPAGE PITS <br />DISTANCE T EAREST WELL ft FOUNDATION ft PROPERTY LINE <br />NuMBER WET" L ft DEPTH aS <br />ft <br />ft <br />DISTANCE TO'NEAREST WELL�Ift FOUNDATION DftPROPERTY LINE <br />R <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 />Application Accepted By <br />Final Inspection By_�; <br />Character of Soil to Dept <br />COMMENTS/)k- <br />DATE ✓ —��^P� <br />1 Employee ID# <br />PERMIT -Approved by <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />