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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 c �s - � <br />CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROOMt DATE ISSUED <br />-2- <br />CROSS <br />D `` 71� �T• 1"2— CITY/ZIP E1=� !T z•71 <br />JOB ADDRESS I ,�}� • `1 r p v <br />CROSS STREET I'^''7 6o APN - 2'PARCEL SIZE S'L G• <br />OWNER NAME � 13G�-T 02-4G 0PHONE It 0) 301 - " - 1 <br />CITY/STATEIZIP Lob I <br />OWNER ADDRESS �7 Z S�� _ <br />CONTRACTOR (+ a? K �("•��'I�V'v rr� PHONE -3(ol-O K <br />t f 0-7 L). 0 �T - CITY/STATE/Z., <br />t_OnI " �1�2�iA <br />CONTRACTOR ADDRESS <br />� <br />ccU -3n -zZ <br />LICENSE Li'. '..0-42 ❑I.'. C-36 OTHER NUMBER Z(1 1 EXPIRATION DATE <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # I —� BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: I 1 NEW INSTALLATION <br />II REPAIWADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br />I REPLACEMENT 11 OUT -OF -SERVICE SEPTIC SYSTEM 0 DESTRUCTION <br />[I OTHER <br />INSTALLATION WILL SERVE: ❑ RESIDENCE [I COMMERCIAL NUMBER OF EMPLOYEES: <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />❑ SEPTIC TANK <br />❑ GREASETRAP <br />❑ LIFT STATION <br />TYPE/MFG <br />T—MA1r <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />_ CAPACITY gal # OF COMPARTMENTS <br />CAPACITY gal # OF COMPARTMENTS <br />ft FOUNDATION fl PROPERTY LINE ft <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LJ LEACH LINES <br />! i LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />ft <br />FILTER BED <br />L3 FILTER <br />WIDTH <br />ft LENGTH <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft DEPTH ft <br />L3MOUNDED <br />WIDTH <br />It LENGTH <br />ft PROPERTY LINE ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft <br />SUMPS <br />L] SUMPS <br />WIDTH <br />ft LENGTH <br />DEPTH <br />ft <br />DISTANCE To NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />El PITS <br />NUMBER __ <br />WIDTH <br />ft DEPTH ft <br />ft <br />DISTANCE To NEAREST <br />WELL <br />ft FOUNDATION <br />fl PROPERTY LINE <br />SAN JOAQUIN COUNTY ORDINANCES, <br />THAT <br />I HAVE PREPARED THIS LICAT THEREGULATIONS <br />ORKWIILLB D <br />N <br />ACCORDANCE <br />1 HEREBY CERTIFY <br />STATE LA <br />RULES AND SAN <br />COUNTY. <br />TITLE RIZOJ - M &-12 • _.. DATE <br />DEPARTMENT USt UrvL r y{ <br />Application Accepted By <br />��R� i L Date 3 �� �T. Area I" ( Employee ID# ' 1 <br />Final Inspection By Date ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: pit/Sump Soil Character: <br />COMMENTS <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />42-01 <br />4/14/18 <br />