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I7� <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE-STOCKTON CA 95205 -(209) 468-3420 <br />NUN -11th UNUAtiLt YtKMI I GALL LU`J `JOJ-/DY/ FUH lNSYt C/lUN5 FK <br />rXPIKtS l TtAK UM UAIt155Ut <br />C1 <br />JOB ADDRESS L CITY/ZIP Fra ✓t L N7 - ?J <br />CROSS STREET 1'; rPa r i Wa `i APN 1 q j - 3 t o - (o PARCEL SIZE <br />OWNERNAME Nrl�1 J�G�t.� PHONE / / Iq <br />OWNER ADDRESAS' G S L- 64'4 ' CITY/STATE/ZIP �J F d\) G• / ^ C4wt i L [ / Y? -3 <br />g ) <br />CONTRACTOR l�1Q1 G. Fin so.•.4�.1i 5UI FIG/C <br />S ,) // ��%%[ON CO. PHONE l G.i <br />hoz TAI .t 1 Wa-� CITY/STATE/ZIP wl l Cil /�isz 4 o <br />CONTRACTOR ADDRESS S-1-31/17LICENSE C-42 I - -C-36 OTHER l - S�7 NUMBER i0 1 �O "{ EXPIRATION DATE <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />lr-PERCTEST # <br />1 BUILDING PERMIT# <br />LAND USE APPLICATION # /�-- O IOL <br />TYPE OF WORK: <br />NEW INSTALLATION <br />REPAIR/ADDITION <br />ENGINEER DESIGNED /ALTERNATIVE <br />It PROPERTY LINE It <br />REPLACEMENT <br />OUT -0F -SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL SERVE: I RESIDENCE <br />i I COMMERCIAL <br />I 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 />TYPEIMFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />It <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 <br />LEACHING CHAMBERS <br /># OF LINES <br />Date <br />LENGTH OF LINES _ ft <br />Code INFO <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />Service Request # <br />It PROPERTY LINE It <br />❑ FILTER BED <br />WIDTH <br />It LENGTH <br />It <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />ft PROPERTY UNE it <br />❑ MOUNDED <br />WIDTH <br />it LENGTH <br />It <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />It LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FCUNDATICN <br />11 PROPERTY LINE It <br />❑ DISPOSAL PONDS WIDTH <br />It LENGTH <br />ft <br />DEPTH it <br />DISTANCE TO NEAREST <br />WELL <br />ft FOVNDATICN <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FCUNOATICN <br />ft PROPERTY LINE ft <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />, 7 � STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />SIGNED /"/I- TITLE 544 6)¢0161- -]I / DATE <br />CE ANT <br />Fn <br />2 4 ?015 <br />COUN <br />VTA� Ty <br />Application Accepted By Date `- Area4TjjEmployee ID# <br />Final Inspection By lr' �!1 Date I SPECIAL PERMIT - Approved by <br />Character of Soil to De th of 3 Ft: ili1 PiU Ump Soil Character: <br />Cop' 7AENTS <br />PE SC <br />Received I Che-- <br />rZ°ash <br />Amount <br />Date <br />PermIV Invoice # Permit ION <br />Code INFO <br />B <br />Remitted <br />Service Request # <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />424/12 <br />