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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 CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS// � — KJ L QCIITY/ZIP <br />CROSS STREET /%a" {1/Jt APIN J� v 0 �AD 17— PARCEL SIZE G� <br />OWNER NAME PHONE <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />CONTRACTOR_/-lC'o PHONE <br />CONTRACTOR ADDRESS ���i�t^� /�/i!L �i� CITY/STATE/ZIP <br />LICENSE ❑A--42 Ell -IC -36 OTHER NUMBER yS9(%YS EXPIRATION DA <br />WATER TABLE DEPTH: 114\v) 60 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: L NEW INSTALLATION 04, REPAIR/ADDITION i ENGINEER DESIGNED /ALTERNATIVE <br />❑ REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG '4X' y��'j <br />CAPACITY Z( co gal # OF COMPARTMENTS <br />(Check# <br />ash <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />Invoice # <br />Permit ID# <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />I2- 18.217 <br />LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES _� LENGTH OF LINESO <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE /OO r <br />ft <br />❑ FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE To NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />9- SUMPS ® <br />WIDTH ! I ft LENGTH � <br />i ft DEPTH /y / <br />ft <br />DISTANCE TO NEAREST WELL% 510 ' ft <br />FOUNDATION f C!y ;-- ft PROPERTY LINE 1Q0 v- <br />ft <br />❑ DISPOSAL PONDS <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />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 OF SAN JOAQUIN COUNTY. <br />MINIMUM 48 <br />HOUR ADVANCE NOTICE REQUIRED <br />FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED <br />TITLE DATE IZ11 S- Z6 <br />UN O <br />H T <br />��LE,EARTMENTkISE O LY ye <br />�! 7,)e` rI`� <br />Application Accepted <br />y Date <br />2 - IS Area Employee ID# <br />Final Inspection By <br />Date <br />°2 ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to De th of 3 Ft: <br />Pit/Sump S 'I Characte <br />COMMENTS <br />j Gl% t1J . i <br />So - <br />PE <br />Code <br />SC <br />INFO <br />Re ived <br />(Check# <br />ash <br />Mnount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />--By- <br />3C <br />I2- 18.217 <br />�JIQDO'$ <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />