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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-KEFUNDABLE PZERMIrT7 GALL ZU9 953-7697 FOR INSPECTIONS A / LXPIRES 1 YEAR FROM UATE ISSUEI <br />JOB ADDRESS /✓� r�l / �/ !n ( - CITY/ZIP /t' o Y <br />CROSS STREETI-'G/uL p APN �J I� " PARCEL SIZE <br />OWNER NAME Y�PY T� Oe n d y Ma f e V `. Z- PHONE <br />OWNER ADDRESS <br />////�����SGi N')E- I // ///�/ /�(�/,' CITY/STATE/ZIP <br />CONTRACTOR CamN q v 4t % c�'e / G PHONE <br />CONTRACTOR ADDRESS Y��°��j/�� / CITY/STATE/ZIP <br />LICENSE ❑I,AC-42 ❑CIC -36 OTHER NUMBER [ f 5?0/EXPIRATION DATE �c3 <br />WATER TABLE DEPTH: �� �[iy ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ <br />PERC TEST # BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ENGINEER DESIGNED /ALTERNATIVE <br />Date <br />11.REPLACEMENT ❑ OUT <br />-0F -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ <br />COMMERCIAL ❑ OTHER <br />)�5'30� <br />e <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG ! 1`N� <br />CAPACITY gal # OF COMPARTMENTS <br />GREASE TRAP TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES LEACHING CHAMBERS <br /># OF LINES a l LENGTH OF LINES <br />rL <br />DISTANCE TO NEAREST WELL / SO I ft <br />r <br />FOUNDATION &0 / ft PROPERTY LINE / ft <br />❑ <br />FILTER BED WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDA14ION ft PROPERTY LINE ft <br />❑ <br />MOUNDED WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SUMPS WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEARE T WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH c2!5- <br />2SDISTANCE <br />L3CQ <br />DISTANCETO NEAREST WELL l 7 ft <br />FOUNDATION &O Z ft PROPERTY LINE / O ft <br />T 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 <br />OF SAN JOAQUIN COUNTY. <br />MINIMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />-48 <br />SIGNED /��C_ - <br />TITLE L011kCff DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By -L�� Date 1 1a as Area Employee ID#ftn� <br />Final Inspection By Date - - V l L t 2 Z ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS el,() -004 IIY,f-s for MO), ALA)766")7G- )700h II►1e (as DUD! G'11<' aE4n� <br />�� I i/ �..>� ✓� . 1:., ' - :111%rel <br />PE <br />Code <br />Sc <br />INFO <br />Received <br />B <br />Chec <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />Llalo <br />)�5'30� <br />12.22 <br />S2 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />