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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 -(209) 468-3420 NON-KEFUNDABLF VERMIT GALL (ZU8)80J-/b8/ FORINSPECTIONStXPIRES 1 YEAR F M DATE 155 -VE JOB ADDRESS 73 BUILDING PERMIT # LAND USE APPLICATION # C� t C1 f 'CIITY/ZIP I O REPAIRIADDITION CROSS STREET J APN COO I PARCEL SIZE IF I OWNER NAME �(�( �r I'-� PHONE ,3 ❑ COMMERCIAL ( �y OWNER ADDRESS `C CITY/STATE/ZIP ❑ SEPTIC TANK CONTRACTOR LA �% /( U PHONE / r� -y` uel -rLl CONTRACTOR ADDRESS CITY/STATE/ZIP /h _ LICENSE ❑OC -42 ❑t/36 OTHER NUMBER loaSq /,L1J 6EXPIRATIONDATE y/3��e It FOUNDATION It PROPERTY LINE ft ❑ LIFT STATION WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: L NEW INSTALLATION _ REPAIRIADDITION '-, ENGINEER DESIG ED/ALt,T�ERNATIVE A Semitted I I REPLACEMENT , . OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION Lt n �`- INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL It FOUNDATION It PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES C LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ FILTERBED WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE R ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft DISTANCE To NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPL1CAf1QXAND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS Np'RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMUM 48 HOUR ADVANCE 6TICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 9513-7697 SIGNED TITLE DATE / — 1 r?6 yMENT :CEIVE® 17 2021 n I►N COUNT`( TH DEPARTMENT DEPARTMENT US ONLY ell D Application Accepted B --;:;'1- Z—& DEPARTMENT Date /7 Area L� 7 I Employee ID#/A Final Inspection By S Date ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS pVr he SE'tr1Pr 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 PE Sc Receive Amount Date Permit/ Invoice# PermitID# Code INFO ash A Semitted I I Service Re uest# as I �7s 2b sa y 111 u D 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18