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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 ADDRESS14 S'13Aap,2 N W t CITY/ZIP f <br /> a <br /> A4:, APN PARCEL SIZE_-71 <br /> CROSS STREET pr _ Y <br /> a <br /> a <br /> OWNER NAME G.o fn So L U G���it c:^.t ✓ IC Gill 4cGLU/-g- PHONE <br /> — yllz7 SZz <br /> OWNER ADDRESS ! �P, /+ S ( _ CITY/STATE/ZIP 5-1 ►7Cll WF L 196& <br /> CONTRACTOR fn i (��G) fMe yc (' PHONE H C�n� 2131J <br /> CONTRACTOR ADDRESS2— "�V L- � CITY/STATE/ZIP T L �Xh6 <br /> LICENSE CII!C-42 ❑f IC-36 OTHER A__—NUMBER �~ EXPIRATION DATE T �� <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: t! NEW INSTALLATION REPAIR/ADDITION EI ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT J OUT-OF-SERVICE SEPTIC SYSTEM 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: C NUMBER OF BEDROOMS: —7 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 Ci LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Ul FILTER BED WIDTH 1Ck I ft LENGTH � F ft DEPTH i S (' ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 1-0 '}' ft PROPERTY LINE 91) � 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 /> 0 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 48 H01JR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL 209 953-7699j7 j <br /> SIGNED TITLEC,CY d Pee_-a t' DATE <br /> K GE E <br /> IRON E <br /> H CIE M N <br /> DEPARTMENT USE ONLY <br /> Application Accepted Date �•g.v a Area Employee ID#—D <br /> Final Inspection By i�� Date _ ❑ SP CIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 <br /> `� Pit/Sump Soil Character: <br /> COMMENTS t J v <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> s42z v Its- <br /> 42-01 <br /> -01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />