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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 3 / 11 Alrod /Z CITY/ZIP M/4rj7i-t G14 :-4-3f, <br /> CROSS STREET XFFytpy IaSWEs APN O�J V PARCEL SIZE p <br /> v <br /> II�� <br /> � <br /> OWNER NAME RLcrt-1 5cnea, PHONE <br /> OWNER ADDRESS CITY/STATE//ZIP i' <br /> CONTRACTOR TS �0'VS1-o- 4'C:T•T0eV SFPTre TA/c, PHONE \�) /43 CG S <br /> C1 "2� S <br /> CONTRACTOR A 'DDRESS Y0, 0w &'y CITY/STATE/ZIP elk �12Cr'E r i 9y7as <br /> LICENSE I_vADG-42 I.I 'C-36 OTHER NUMBER EXPIRATION DATE Ce 2 n <br /> 1 <br /> WATER TABLE DEPTH:nl_ O ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE 1 1 COMMERCIAL I OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY f ZV o gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINEs LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> FILTER BED WIDTH ;R U` ft LENGTH 2!4 I ft DEPTH I `p 1� ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 310 ft PROPERTY LINE IVC' ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <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 /> MINIMUM 24 HO R DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE ^t `cLs..�� DATE <br /> L <br /> l <br /> 1-2 <br /> a <br /> I ; <br /> y 2 <br /> I I - <br /> EPARTMENT US it ONLY <br /> Application AccjBy <br /> Date f' Area Employe @ ID# <br /> Final Inspection Date I I SPECIAL PERMIT-Approve tCharacter of SoiF . Pit/Sump Soil Character: RECEIVED <br /> COMMENTS <br /> 71 2019 <br /> z3AN JOAQUIN COUNTY <br /> PE SC Received Chck eAmount Permit/ <br /> Code INFO ash Remitted Date Service Re uest# Invoice# H LTH � tENT <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />