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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRE <br /> S <br /> 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS39 6 kCITYIZIP <br /> CROSS STREET " -e ns R Yl _ 1 AP r.CA- (a 00` aCOO PARCEL SIZE C' <br /> OWNER NAME ->-Q.\o-mo T it C icA PHONE <br /> OWNER ADDRES`SJ� CITY/STATE/ZIP <br /> ci,'At \ ( 6(411{i�( [-yry l �CONTRACTOP <br /> PHONE -t ' C]�r/5�-��JUI(J\� <br /> CONTRACTOR ADDRESS ��X�.O , qITY <br /> a.4 C /STATE/ZIP �In.tJy A <br /> LICENSE 442 ❑ C-36 OTHER NUMBER EXPIRATION DATE Ow <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIRIADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> se' REPLACEMENT A e/C, OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ] OTHER <br /> It NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: l NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG , ,�•�{M a" ) CAPACITY � _ _ gal #OF COMPARTMENTS <br /> L3 GREASETRAP TYPE/MFG /— jCAPACITY 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 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 /> MINIMUM48LI UR ADY4410E410TICE REQUIRED FOR INSPECTIONS-PLEASE CALL 2 953-7697 <br /> SIGNED TITLEDATE <br /> —I— <br /> y V �i <br /> ry <br /> r <br /> L 7ENT USE ONLY DA <br /> Application Accepted By G �y Date4 'I Zozo Area S G Employee ID# <br /> Final Inspection By 1 Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> Nr'.rF� P?j�. <br /> PE SC Received Gheck#/ Amount Permit/ <br /> Code INFO B ash _Remitted Date Service Request# Invoice# Permit ID# <br /> .2Oq IIS- <br /> 42-01 <br /> 4 01 5705-65 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4//'14/18 <br />