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i <br />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 CALL (209) 953-7697 FOR INSPECTIONS EXPIRES.1 YEAR FROM DATE ISSUED <br />JOB ADDRESS I G1 LI C --U ( O lfff 'L"'� LI QTYIZOP 11'rff Li C/ 4' <br />CROSS STREET / r'% �sl APN C CS S /" 3' / PARCELSIZE L (` / <br />OWNER NAME yC G'S VF i / PHONE <br />iTT <br />OVNER ADDRESS CITYISTATEIZIP <br />-! //� <br />CONTRACTOR �L� N I7 [u PI f{��d PHONE LJ <br />CONTRACTOR ADDRESS / 4 / '-1 �'Y ✓1 (1 (�,JI ////�` CITY/STATEIZIP '' Ct r 1Y� <br />LICENSE r C42 C36 OTHER NUMBER r S�G'7 7 ExPIRATON DATE <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />rPERC TEST # <br />BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEW INSTALLATION REPAIR/ADDInoN <br />ENGINEER DESIGNED /ALTERNATIVE <br />WELL <br />REPLACEMENT / lIF) 1- OUT-OF�SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL'? <br />OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG eleGv� �zp CAPACITY ( <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPEIMFG CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST <br />�j <br />DISTANCE TO NEAREST: WELL / ft FOUNDATION 5 , <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES _ <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />❑ DISPOSAL PONDS WIDTH <br />It <br />LENGTH <br />ft <br />DEPTH <br />DISTANCE To NEAREST <br />WELL <br />R FOUNDATION <br />ft PROPERTY LINE <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />ft PROPERTY LINE <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 />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />Character of Soil to DeQth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTeO, k A^1nl1 1 ....:A-4 . <br />PE SC Received Check#! Amount Permit/ <br />Code INFO Cash Remitted —.Service R uest # Invoice # Permit ID# <br />go <br />r <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />rr1 <br />I� <br />