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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT c /y p S CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> T <br /> JOB ADDRESS I S 1 s 1 �`J �'`9<7C- `'j r XD• C CITY/ZIP �Oh 1 p17�ZT 0 <br /> CROSS STREET TA-U L'� / AyPN 053-b l -Up,_C) ro PARCEL SIZE 1-1tv <br /> �-1^1�ry' p <br /> OWNER NAME MPr►'LCrOT �Ty�IIt S 1Zl;` L C C. PHONE _ 1' / r 0e <br /> lA <br /> OWNER ADDRESS SampCITY/STATE/ZIP <br /> CONTRACTOR LIVE: PHONE 3toll <br /> `d3-15' <br /> CONTRACTOR ADDRESS ifo-7 w' 0Me- ST CIN/STATE/ZIP <br /> LICENSE I '.0-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I i NEW INSTALLATION REPAWADDITION ENGINEER DE IGNED/ALTERNATIVE <br /> REPLACEMENT II DESTRUCTION <br /> INSTALLATION WILL SERVE: II RESIDENCE I COMMERCIAL LI OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <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 LEACHING CHAMBERS #OF LINES LENGTH OF LINES 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 It 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 It 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 /> MUM 2400 <br /> ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7887 <br /> SIGNED TITLE G aNSVL110f? -r DATE <br /> PAYMENT <br /> RECEIVED <br /> EP <br /> 10 2019 <br /> S JOAQUIN COUNTY <br /> VIRONMENTAL <br /> --HEALTH DEPARTMENT <br /> DEPART MEN SONLY <br /> Application Accepted By Date Area Employee IO# <br /> Final Inspection By Date 0 7 ❑ S AL ERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Characte. <br /> COMM NTS L E <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO Cash Remitted D to Service Re uest# Invoice# Permit ID# <br /> LI <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />