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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 EXP <br /> IRES 1 YEAR FROM DATE ISSUED <br /> La/�S CITY/ZIP <br /> JOB ADDRESS <br /> CROSS STREET 4J� L Lei f+ APN 2- c7.' PARCEL SIZE • / p <br /> c <br /> / z <br /> OWNER NAME _ �G �Q- h G PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP r <br /> CONTRACTOR J InLA P '��..1/✓ PHONE <br /> CONTRACTOR ADDRESS '1/ eq2 NVJ BpMJ CITY/STATE/ZIP <br /> LICENSE ❑ C-42 ❑I C-36 OTHER NUMBER 1 yrz EXPIRATION DATE <br /> WATER TABLE DEPTH: 422 v ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I NEW INSTALLATION F REPAIR/ADDITION !I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM 41' DESTRUCTION <br /> INSTALLATION WILL SERVE: t RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: ocNUMBER OF BEDROOMS: _-P NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG ♦ CAPACITY �Z OcJ gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION 40-)- ft PROPERTY LINE <br /> ❑ LIFT STATION SIZE TYPE OF PUMP,^ ./ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES P LEACHING CHAMBERS—.F Z / #OF LINES LENGTH OF LINES 7 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <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 ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 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 REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 48 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL 209 953-7697 <br /> SIGNED TITLE �A Z� �� DATE 7 �' <br /> V ul' U711 <br /> T D A <br /> DE ARTMENT USE ONLY ,A?,K <br /> Application Accepted By � Date Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Dept of 3 Ft: "PitAsiUmp Soil Character: <br /> COMMENTS <br /> 60 <br /> r- <br /> PE SC III Received heck Amolint Date Permit/ Invoice# Permit ID# <br /> Code INFO B emitted Service Request# <br /> -7 y o <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />