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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT- U- CALL 209 95p3-7697 FOR INSPECTIONS � � EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �� <br /> . AA6c2zD L LA?t�SDAL` I"�' CITY21P ACAMPD 75-2-2-0 <br /> -(r, y <br /> q ��7,}-rte./�. 7 �y <br /> CROSS STREET HW� 9 1 �• ��^-�•••"' APN QI �I-OLID-� -L�.4PARCEL SIZE �� A b <br /> e , �/� <br /> OWNER NAME CjkGj f-02A.11 A coaw(�.l,-rF�T�1t J-c co.Go PHONE <br /> /•y 33y--p�,J 1 q p1�- <br /> OWNER ADDRESS V `+� V �' • - / I CITY/STATE/ZIP ('c A-M('�J0 C,\ L ZQ <br /> a <br /> CONTRACTOR i-I yr GOF�1L Ce DENVI20N 1"ItAj-j^L PHONE .3 1Vq` C)3C)3-;�S e G �../.. <br /> CONTRACTOR ADDRESS S 7-. CITY/STATEIZIP <br /> LICENSE L.C-42 I C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> �Q PERC TESTI# BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I. NEW INSTALLATION REPAWADDITION I ENGINEER DESIGNED/ALTERNATIVE <br /> G REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: I RESIDENCE 1 COMMERCIAL i OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY 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 ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH It <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 It PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH It 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 2 R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE CNSI I1tAJ1 DATE - -' <br /> GL <br /> r <br /> STATE MGHIIWIAy ROUTE W <br /> J� �' •���J 111„___����jjj I I.'amu-. <br /> a luu YI n � J1T' £ <br /> Ir'I u IL <br /> �11�� PAYMENT <br /> _ = DECEIVED <br /> HAR 1 1 2019 <br /> AN JOAQUIN COUNTY <br /> ----------------�;„�--------------------- .,�-�- ,^,m,- i ENVIRONMENTAL <br /> s�-ALAN Z, EALTH DEPARTMENT <br /> ' FFF -.-,-H <br /> 11111111111111111 <br /> EPARTMENT USEON �o <br /> Application Accepted B Date Area Employee ID#� ' ^ <br /> Final Inspection By Date 3 CI SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE Sc Received h Amount Date PermiU Invoice# Permit ID# <br /> Code INFO B Cash Remitted ServicLo Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />