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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 <br /> J PERMIT A CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1AYEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> CROSS STREET APNPARCEL SIZE i C <br /> J d <br /> OWNER NAME ,1�5ILA I Z �����jG PHONE.�04 bd�Zg <br /> OWNER ADDRESS ) _CITY/STATE/ZIP �J <br /> CONTRACTOR �, �f ye::��'?iii/}/�,IS� ���__ PHONE <br /> CONTRACTOR ADDRESS y/b z2 �'"``7�7�� � CITY/STATE/ZIP <br /> LICENSE ❑I!C-42 ❑OC-36 OTHER—/ NUMBER Jv EXPIRATIONDATE <br /> WATER TABLE DEPTH: _ ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: D NEW INSTALLATION ❑ REPAIR/ADDITION CI ENGINEER DESIGNED/ALTERNATIVE <br /> U REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM IJ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE CI COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: ) NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG � / � i CAPACITY ��C7 gal #OF COMPARTMENTS !i <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ;E( LEACHING CHAMBERS 4:2 #OF LINES�_ LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 1/J!�L_ It 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 '/ b ft DEPTH ) -2— ,✓ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ��O ft PROPERTY LINE S 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 /> 1 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 /> MINIUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)9953-7697 <br /> SIGNED TITLE DATE AO— <br /> AT <br /> T <br /> DEP <br /> Ll <br /> ,D PARTMENT U E O LY <br /> Application Accepted y _ ___._____ Date Are' Employee ID# F_ <br /> Final Inspection By __ Date Z ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil t ept o 3 F . Pit/Sump Soil Character: <br /> COMMENTS I Lj <br /> � _ � ��;�ot�o• ��� c.>� .haw �,eu, <br /> PE SC Received Check#/ Amount to Permit/ Invoice# Permit 1D# <br /> Code INFO B Cash Remitted Service Request# <br /> 2nhf 5?100919150 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />