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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 ExPPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 7&A) .•` A� CITY/ZIP % 57�,F'�6 <br /> C iL' Cy v <br /> /� �f =j <br /> CROSS STREET J I �Aq <br /> ` /tr ` APN /VO 7 PARCEL SIZE <br /> �G( <br /> /"C c <br /> OWNER NAME LvPHONE <br /> OWNERADDRESS 1/70? C V Cdy! C'"/(_ CITY/STATE/ZIP /`-C/J�1 �/�•� !�S(!/� K, <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ 'C-42 01 IC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # , BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: .0'-RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: � NUMBER OF EMPLOYEES: <br /> ,SEPTIC TANK TYPE/MFG CAPACITY 2OD D gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ` Q 1 ft FOUNDATION ft PROPERTY LINE It <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBERS #OF LINES 3 LENGTH OF LINES O�I � ft� ` <br /> Y <br /> DISTANCE TO NEAREST WELL ft FOUNDATION I ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ZIA ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH lxt�cElty <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ono <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE SAN-104 .ully. <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ENVI C�UMI <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE FI 1)EAAar.._NT <br /> 1 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 /> M/ MUM 48 HOURA C OTICE REQUIRED FOR INSPECTION -PLEASE CALL L20&153-7697 <br /> SIGNED TITLE DATE U <br /> Al 11 <br /> 1 <br /> I <br /> l <br /> l/ a DEPARTMENT SE _DWArea - Employee ID# � � "e4 <br /> Application Accepted B Date <br /> Final Inspection By Date 2 AZO ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PiVSump Soil Character: <br /> COMMENTS lie 15- z()&2 P l r er Cmri ,4,.CA.> �n r-0q)_" +13 t-IMI—li 7b ic( <br /> AL�0 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By_ Cash Remitted Service Request# <br /> 42�I 2- 5 I-IUD 15V-00-1—D-111-344 <br /> 42-01 / 7 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> /) <br /> 4/14/18 1���6 �L2-0 <br />