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S <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-REFUNDABLE PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROMDATE ISSUE[ <br />JOB ADDRESS <br />J b <br />G CITY/ZIP <br />)rl�✓ <br />¢�' ) <br />CROSS STREET /'- l�,�y <br />APN� �A -��� <br />PARCEL SIZE v� <br />OWNER NAME Z//-) <br />SIZE TYPE OF PUMP <br />PHONES[(/7 ✓%L�3 <br />OWNER ADDRESS <br />LEACHING CHAMBERS <br />CITY/STATE/ZIP <br />ft <br />�/' <br />CONTRACTOR —Al,I6fiAi op -5 /!y/j1�i{��/7�� <br />�X9�+, PHONE <br />CONTRACTOR ADDRESS �G�� <br />'!/ <br />CITY/STATE/ZIP <br />ft <br />LICENSE _: C-42 r] C-36 OTHER <br />WIDTH ft LENGTH <br />L <br />NUMBER,?,567 EXPIRATION DATE <br />�2- g j `�� <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />I PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION EPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT 1', OUT -0F -SERVICE SEPTIC SYSTEM DESTRUCTION 7Q<L<A4 <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL U OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: _ 17 , .1 NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG -�17%QIf) Zl e17r <br />` rj CAPACITY/ gal # OF COMPARTMENTS <br />Invoice # Permit ID# <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />, <br />DISTANCE TO NEAREST: WELL �b 7 <br />')) <br />ft FOUNDATION S Y ft PROPERTY LINE } ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />LEACHING CHAMBERS <br />#OF LINES /I LENGTH OF LINES �y <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />�dx SUMPS <br />WIDTH X ft LENGTH <br />/,2- ft DEPTH D' <br />ft <br />DISTANCE TO NEAREST WELL�]p )-Z <br />r <br />ft FOUNDATION �� 2� ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />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 <br />OF SAN JOAQUIN COUNTY. <br />MINIMffM 48 <br />HOUR A LANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-769j7G_ <br />� J 2 <br />SIGNED <br />TITLE �/ DATE / - <br />Application Accepted By - <br />Final Inspection By <br />Character of Soil to Depth <br />COMMENTS / oD/ - j <br />T <br />T <br />EPARTMENT fJ S EO N L Y M� <br />Date Area -` Employee ID#D. Arzhk <br />Date C SPECIAL PERMIT - Approved by <br />Pit/Sump Soil Character: <br />�i�-+,• ��v3 � 't � � � Ili � z <br />PE SC Received Check#/ <br />Code INFO B Cash <br />Amount Date <br />Remitted I <br />Permit/ <br />Service Request # <br />Invoice # Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />