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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 1 CALL�209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS (.7 0 S TP Roo oo Te -722 CITY/ZIP 5��,Mki 75X <br />CROSS STREET j� �I CC' V I I APN `IDI PARCEL SIZE a��S S <br />OWNER NAME (wa.l� L PHONE� • — -2,7`T6 a� <br />OWNER ADDRESS SSoo OvrAmf <br />//C k Lr J CITY/STATE/ <br />ZIP Jxwr'0&�P C n- <br />CONTRACTOR NGqg ert H (OF, rVtrlcg^ PHONE��rg (•>�t� �S�•P �/ <br />CONTRACTOR ADDRESS (W��/Gwar� 'ir q�[ ^ {/CITY/STATE/ZIP J �C t) / O <br />LICENSE 17C-42 [1 C-36 OTHER 1-� NUMBER / r d � EXPIRATION DATE/ <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND 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: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑A <br />SEPTIC TANK <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />/�Jjy(�Ij <br />GREASE TRAP <br />'[ D <br />TYPE/MFG J (jV1SQ � <br />!� <br />CAPACITY O OD gal #OF COMPARTMENTSY Ot <br />., c4D <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />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 REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINII14UM 48 <br />HOUR AIDVANCE NOTICE REQUIRED <br />FOR INSPECTIONS - PLEASE CALL (2091953-1697 <br />r a <br />SIGNED <br />TITLDAT of <br />Ey� <br />! i <br />Z, <br />DEPARTMENT USE ONLY <br />�� Z -1Z, <br />Application Accepted By Date Area y�i Employee ID# <br />Final Inspection By Qz,^i�L ALI Date ' F-1SPECIALPERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS P001C sewer s, r" r P <br />IJ <br />.ApY oT :Tarn r,r,��rrll;7G, af• <br />PE <br />Code <br />SC Received <br />INFO By <br />Check#/ <br />as <br />Amount <br />Remitted <br />at Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />Z- <br />., c4D <br />g v0g53"7 <br />Cr <br />42-01 G " 1 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />