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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,tPERMIT ♦ CALL 209 953-7697 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS [+-F T I �I E• COLLI E t2-- /'-i^• CITY/ZIP A<&"rVA I­r q�y Z V Z' <br /> H <br /> CROSS STREET Fu I i z_w'A N APN CI Z I - O 3(� -3�� PARCEL SIZE ' �' •�- p <br /> QQ qq y� A�.,////��,,�� � ,\ I` 0 <br /> OWNER NAME n `F-r`E-LG �7`Vru"_� PHONE 4-)C! -(r�2-2- N <br /> OWNER ADDRESS 2-te 1 a /N��� 'I w� CITY/STATE/ZIP ���Gt <br /> CONTRACTOR "V ''UIIp-y &EDEJMV'N/2'Q'JjnC�L PHONE '3`' ` 3-7 5- <br /> CONTRACTOR ADDRESS <br /> "['c)-1 �• 0 Ale 5T' CITY/STATE/ZIP <br /> LICENSE IC-42 I IC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # F BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I 1 NEW INSTALLATION 1 1 REPAIR/ADDITION I i ENGINEER DESIGNED/ALTERNATIVE <br /> II REPLACEMENT II DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE I COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK 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 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 24HOURADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED sem' '�— ``/G.�'� TITLE CD/VSUUny J r DATE )(-I <br /> sAll �EjO <br /> �F® <br /> AN <br /> 2019 <br /> T NTq 1V7'y <br /> TMFNT <br /> DEPARTMENT U E ONIL <br /> C <br /> Application Accepted By Date Area , Employee ID# <br /> Final Inspection By Date / SP L PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit&ump Soil Character: <br /> COMMENTS <br /> z S e C r_^—j( !i�l� r►t;//t i ISG <br /> 2 o /.:h %oje_k. nikj <br /> PE SC Received Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted ServiqoReq pest# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />