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ti <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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> CrrYlLP C 4 n <br /> ACA"IfQ [J q <br /> CROSS STREETC� APN Oz3_tof,t—�3 PARCEL SIZE �7' �•`� D /1 <br /> c l \J <br /> OWNER NAME /1h/ �//PHONE N <br /> OWNER ADDRESS .BGX r/O -c CRY/STATE/ZIP 6 w!- (, 4t,�9��7i� <br /> CONTRACTOR •r IIS� MS PHONE <br /> //�� !Q 11 <br /> CONTRACTOR ADDRESS y• 51� �� CA /SaeB <br /> CfTI'/$iATE/ZIP /'� 1. (I 1 <br /> LICENSE ❑Y-+2 ❑_C,T6 OTHER NUMBER EXPIRATIONDATE /0--31 —.1& <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X y <br /> 0 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# ^� <br /> TYPE OF WORK: _ NEW INSTALLATION REPABt/ADDRION = ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT J OUT-OF-SERVICE SEPTIC SYSTEM _ DESTRUCTION /1 <br /> [INS;T�ALSERVE: RESIDENCE ❑ COMMERCULL ❑ OTHERG UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS (vim <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE fl r� Sn <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SANB OIL SEPARATOR(ENCLOSED SYSTEM) ll'�• ~ <br /> `{p LEACH LINES F LEACHING CHAMBERS #OF LINES LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL 00 ft FOUNDATION , ^ <br /> R PROPERTY LINE <br /> ❑ FILTER BED WIDTH ft LENGTH R DEPTH <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY ONE ft M1 Y <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft `DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl mot\ 1 <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH It C <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER I WIDTH R DEPTH / {t <br /> DISTANCE TO NEAREST WELL D ft FOUNDATION ` <br /> IC>D R PROPERTY LINE fl <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPUCATION AND THE WORK WILL BE DONE IN ACCORDANCE WfTH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM48 HOU DVANCE NOTICE REQUIRED FOR INSP TIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE / DATE 3-,�2-2` D <br /> y U t <br /> r <br /> r L <br /> �r19c�1 5 <br /> ri? <br /> DEPARTMENT USE NLY <br /> Application Accepted By Date Area Y/9 A Employee ID# dog4�� <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received -Ehecld//' Amount Permit/ <br /> Code INFO By Cash Ilemitted Date Service Re uest# Invoice# Permit ID# <br /> /l ✓�37 <br /> 42-01 <br /> 4/14/18 ONSI TE WASTEWATER TRTMNT SYSTEM PERMFT <br />