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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1869 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION:`. Coordinates X Y <br />X PERC TEST # 3BUILDING <br />PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK:. <br />I NEW INSTALLATION <br />REPAIRIADDITtON <br />I I ENGINEER DESIGNED (ALTERNATIVE <br />i <br />REPLACEMENT <br />f-. OUT -OF -SERVICE SEPTIC SYSTEM is DESTRUCTION <br />INSTALLATION WILL SERVE: <br />❑ RESIDENCE <br />❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING <br />UNITS: <br />NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />- gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG. <br />CAPACITY <br />gal: # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />it FOUNDATION <br />it PROPERTY LINE : ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP O PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />1, LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES It <br />DISTANCE TO NEAREST WELL <br />it FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED " <br />WIDTH It <br />LENGTH <br />it DEPTH it <br />DISTANCE TO NEAREST WELL <br />R FOUNDATION <br />ft : PROPERTY LINE It <br />❑ MOUNDED <br />WIDTH it <br />LENGTH <br />it DEPTH it <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH it <br />LENGTH <br />it DEPTH It <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION <br />it PROPERTY LINE _ It <br />❑ DISPOSAL PONDS WIDTH it <br />LENGTH <br />ft DEPTH r it <br />DISTANCE TO NEAREST WELL <br />- It FOUNDATION <br />` ft PROPERTY LINE _ it <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ftk DEPTH it <br />DISTANCE TO NEAREST. WELL <br />It FOUNDATION <br />ft :. PROPERTY LINE ft ` <br />I HEREBY CERTIFY THAT <br />1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS AND <br />RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />VMI# <br />'. SIGNED <br />110M AQjj$W NOTICE <br />REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE Staff Scientist! Consultant DATE 011"19-2021 <br />PAYMENT <br />RECEIVED <br />V 3 0 2021 <br />OAQUIN COUNTY <br />1RONMENTAL <br />TH DEPARTMENT <br />------------ <br />Application Accepted By <br />I" ARTMENT US ONL Y <br />Date_ <br />Area 4 Employee ID#--�T �2•/ <br />Final Inspection By <br />Date <br />❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3/Ft: <br />Pit/Sump Soil Character: <br />COMMENTS '3 <br />h�fe�C <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14118 <br />