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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 E <br />`X'PIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS _ -_ (oQ f � - L\ si N F— r�-T> - CITY21P -T 9 Pk- C ^� �� 0 14 <br />Gr <br />CROSS STREET C" P— 15 M R N APN `� �� 0' O 3 S PARCEL SIZE 0 -I � <br />i K+ . <br />OWNER NAME q Cro 'TD'PD fZ""t ti PHONE &10 -Op,OT <br />OWNER ADDRESS ` 0 H N ry�'pli'M eS tn.J N� CITY/STATE/ZIPp fQL 1 Pa ►v c�� q �3 (0(0 <br />CONTRACTOR L -XJ E U �YK_ CrEo �r�.lV 12Av �>r �rT'A :. PHONE iP 1 -b3-I J Q � / <br />CONTRACTOR ADDRESS 4 d, W ` P Y-- ST 1 CITY/STATE/ZIP Lot! I C^ - l �Z T O <br />LICENSE ❑;.....0-42 EI OTHER �v NUMBERy1 1 EXPIRATION DATE �0'ZZ <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />PERC TEST # <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEW INSTALLATION ._. <br />REPAIR/ADDITION <br />a ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT .... <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE -ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />�P <br />C�I <br />O FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH <br />A <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH Ohl /Vft <br />L e� <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />G ` <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH O <br />13 DISPOSAL PONDS <br />DISTANCE TO NEAREST <br />WIDTH <br />WELL <br />ft LENGTH <br />ft FOUNDATION <br />ft PROPERTY LINE61 <br />ft DEPTH -=U— ��,�YYY <br />COUA, <br />`',iV ry <br />I .1x14617' <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ftA <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE 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 <br />REGULATIONS OF SAN JOAQUIN <br />COUNTY. <br />MINIMUM 48 fffQW ADVANC TI E REQUIRED INSPECTIONS - PLEASE CALL 209 953-76 7 <br />SIGNED TD'LE 1� Irv, �� V-2 DATE 1 <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Depth Of 3 <br />COMMENTS <br />IL Y <br />(! Area <br />❑ SPE IAL PERMIT <br />Soil Character: <br />Employee ID# <br />Approved by <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />