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/ r <br />ONSITE WASTEWATER FREA'i MENT SYSTEM PERMIT J <br />SAN JOAQUIN COU E VI O MF�IjAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 .(209) 468-3420 <br />NON-REFUNDA ITV r CALL 2C09 953-7697 FOR INSPECTIONS p /� EXPIRES 1 YEAR FRRM DATE ISSUED <br />JOB ADDRESS e --'rt-► E. -a-,;) - CITY/ZIP \ u \C --Y1 1; S�O in Y� <br />CROSS STREET • � �C Acs \♦�4' &�7j (y / <br />`` APN i PARCEL $¢ <br />OWNER NAME?zt:,fYL � `�C `� ( G �-7� /.�jP/H�ONE S,o -�3Z)�� <br />OWNER ADDRESS V� t •' �+� I-��L. Ki+� t� CITY/$TATE/ZILP ���442!5- <br />CONTRACTOR <br />'�I g5aP CJS -3 <br />CONTRACTORS "��Q�C %t�.j `J`A���%' A�►�� C^SZI�.J L� PHONE ?�(��442!5- �1 <br />CONTRACTOR ADDRESS �I 1 �-i '�°''��"'tY CITY/STATE/ZIP i' Iv%- k' -;+,z) <br />a <br />LICENSE ❑LC -42 ❑GC -36 OTHER NUMBER04�l,bb EXPIRATION DATE <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />❑ PERC TEST # <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />-i NEW INSTALLATION L <br />REPAIRIADDITION <br />U ENGINEER DESIGNED /ALTERNATIVE <br />It FOUNDATION <br />i. I REPLACEMENT: <br />OUT -0F -SERVICE SEPTIC SYSTEM <br />'Ile DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: 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 />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTERBED WIDTH It LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION <br />It PROPERTY LINE ft <br />❑ MOUNDED WIDTH ft LENGTH <br />It <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS WIDTH ft LENGTH <br />ft <br />DEPTH It <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH It LENGTH <br />ft <br />DEPTH It <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />It PROPERTY LINE ft <br />I HEREBY CERTIFY THAT WAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />'J(. STATE LAWS AND RULES <br />AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINIMUM -N; -HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONn�SAA- <br />PLEASE CALL 209 953-7697 <br />SIGNED <br />TITLE -5t-C7 <br />DATE fo--L--%93 <br />Application Accepted By n Date -j -- Area s <br />Final Inspection By ���! Date 7 l!j�r ❑ SPE <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soli Character: <br />COMMENTS <br />SECT�e1V <br />EIV <br />ED <br />JUN 2 0 2018 <br />SAN JOAQUI <br />ENVIRON N COUN7Y <br />MENTAL <br />HEALTH DEARTH NT <br />Employee ID#,f!!�� <br />-Approved by <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />