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t <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 GALL (ZUU) y53 -/6y/ FOR INSPECTIONS tXPIRES "I YEAR FROM DATE ISSUEI <br />JOB ADDRESS �/ /�j� CITY/ZIP <br />CROSS STREET APNy I (J� PARCEL SIZE S'3(0 <br />OWNER NAME J e i PS�/1 �e s U j � Jf'Z PHONE 22 C�� � � i/✓� <br />OWNERADDRESS CITY/STATE/ZIP �} <br />CONTRACTOR /l `C. 4444' �/'(/���_ 4 J �X V. - PHONE . �j'q qG / (�4/0 <br />CONTRACTOR ADDRESS�(7^ ~_,,rt �/�✓Y C/� FJ CITY/STATE/ZIP <br />LICENSE 11❑C-42 *C-36 OTHER NUMBER. : as EXPIRATION DATE��% <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT #_, p' 1001U_ LAND USE APPLICATION #_ <br />TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESI( <br />❑ REPLACEMEN ❑ OUT -OF -SERVICE SEPTIC SYSTEM D DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />❑ OTHER <br />NUMBER OF EMPLOYEES: <br />TERNATIVE <br />Dd— SEPTIC TANK <br />TYPE/MFG <br />CAPACITY -/Ili0 gal <br /># OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal <br /># OF COMPARTMENTS <br />FOUNDATIONft <br />DISTANCE TO NEAREST: WELL �'�J/> �- <br />ft FOUNDATION J ft <br />PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />f LEACH LINES <br />❑ LEACHING CHAMBERS <br />#OF LINES <br />LENGTH OF LINES�3 <br />ft <br />Invoice # <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATIONft <br />PROPERTY LINE 1 l�' <br />ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />SEEPAGE PITS <br />NUMBER 1S <br />WIDTH <br />ft <br />DEPTH '!iS l <br />ft <br />DISTANCE TO NEAREST <br />WELL Z<_ ? ft <br />FOUNDATION / % <br />ft PROPERTYLINE�� <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 OF SAN JOAQUIN COUNTY. <br />Application Accepted By <br />Final Inspection By__� <br />Character of Soil to Depth <br />COMMENTS S CCOI <br />Ly <br />_ Area / Employee 0#Ft 4 Vi <br />❑ SPECIAL PERMIT -Approved by <br />Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Received Check#I <br />B S <br />Amount <br />Remitted <br />Date Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />41a�1 <br />)-726025 <br />��.� <br />lD to <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />42-01 <br />4/14/18 <br />b <br />7y <br />Cn <br />