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JOB ADDRESS CROSS STREET OWNER NAME OWNER ADDRESS CONTRACTOR NON -REFUND28PE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X LAND USE APPLICATION # BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION REPLACEMENT # OF COMPARTMENTS # OF COMPARTMENTS PROPERTY LINE SEPTIC TANK GREASE TRAP TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL A&I-125%'- CAPACITY WO gal CAPACITY gal ft FOUNDATION ft PKG TX PLANT U SAND OIL SEPARATOR (ENCLOSED SYSTEM) ft FOUNDATION DISTANCE TO NEAREST WELL WIDTH ft LENGTH DISTANCE TO NEAREST WELL WIDTH ft LENGTH DISTANCE TO NEAREST WELL DATE (A) FEB 2 5 2E22 ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAzEt.ToN AVENUE - STOCKTON CA 95205 -(209) 468 -3420 CALL (209)953-7697 FOR INSPECTIONS CITY/ZIP APN4C1 CITY/STATE/ZIP EVRFRp11/pATE,ISAA2 PARCE SIZ PHONE cn PERC TEST # INSTALLATION WILL SERVE: NUMBER OF LIVING UNITS: Li REPAIR/ADDITION ENGINEER DESIG D /A TERNATIVE I L., Ii OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION Ondr 0 COMMERCIAL OTHER NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: LI LEACHING CHAMBERS # OF LINES WIDTH DISTANCE TO NEAREST WELL WIDTH LENGTH OF LINES ft PROPERTY LINE ft DEPTH ft PROPERTY LINE ft DEPTH ft PROPERTY LINE ft DEPTH ft PROPERTY LINE ft DEPTH ft PROPERTY LINE LEACH LINES FILTER BED MOUNDED SUMPS DISTANCE TO NEAREST WELL ft FOUNDATION SEEPAGE PITS NUMBER DISTANCE TO NEAREST WELL ft FOUNDATION I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. 4 HOUR AVANCEAQIIC_E REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 PAYMENT RECEIVED ju,kOUIN CWNTY IROMMINTAL DEPARTMENT SIGN 7 TITLE •••• V rA. ce Application Accepted By Final Inspection By Character of Soil to Depth o COMMENTS frke, ta2it k acew4 -Qqr-10 - 0 g".cd Date SPECIAL PERMIT Pi Sump Soil CXacter: rP_CE 614 a 11W c/14<e4tlik 104- Employee ID# - Approved by aiw siAce Aemse_ 141__s rep Date ?ci_t,77 Area DEPARTMENT USE NLY PE Code SC Received By Check#/ Cash Amount Remitted _ Date Permit/ Service Request # Invoice # Permit ID# 1 1+210 INFO ‘ ,--- /t5 / P.P,k( /51--- ,- OU 5\k00g49/--.V n . _ . -I0.7.1 - ...elf-, L- 17-,_,...471t4/ I 3 0 SITE WASTEWATER TRTMNIF SYSTEM PERMIT /OW 1,& D(-0 v:rv3 Cc- CITY/STATE/ZIP EXPIRATION DATE CONTRACTOR ADDRESS LICENSE 00C-36 OTHER NUMBER ft LIFT STATION SIZE TYPE OF PUMP PHONE 0 RESIDENCE ft ft ft ft ft ft ft ft ft ft ft ft ft FOUNDATION ft FOUNDATION ft FOUNDATION DISPOSAL PONDS WIDTH ft LENGTH ft LENGTH ft DEPTH ft PROPERTY LINE 42-01 4/14/18