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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 . r%. In NON-REFUNDABLE PERMIT CALL ZU9 yb3-/by/ FOR 1NS1'tcL1U1Vb JOB ADDRESS // / / CITY/ZIP CROSS STREET f O j/ /1y_Z/ APN / �I ' OWNER N I GArimr-o 1 1 GMn 1-nvin vr+� .v /7 . q' -73 J PHONE PARCEL SIZE OWNER ADDRESS t'� �I l�/a Uel CITY/STATE/ZIP I' V J(,I JZ L Lzar4�4P!7 1 CONTRACTOR i / !/I�� Zf/JVt�-l�Q{ "�L PHONE CONTRACTOR ADDRESS %/�2 % !i Vl z-/ CITY/STATE/ZIP LICENSE i0C-42 ❑0C-36 OTHER NUMBER. ® F EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION RE�A_IR+/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE FI REPLACEMENT D OUT -OF -SERVICE SEPTIC SYSTEM C7 DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS Permit ID# ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE 231 if e TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION c ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MIN UM 48 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 G 1, DATE SIGNED ! TITLE EPARTMEN U E ONLY Application Accepted By Date ti Area Employee ID#U • l►'G'"' Final Inspection By Date ❑ SP CIAL PER IT -Approved by Character of Soil to Depth of 3 t: Pi ump Soil Character: COMMENTS Sc Received INFO Check#/ Cash Amount Remitted D to Permit/ Service Request # Invoice # Permit ID# Zd 3 8 22 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 42-01 4/14/18