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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRESQ1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �yZX <br /> :5 �1 I-P��V 0-�. CRY2h <br /> 1P Acjq PL) /� y2� ' <br /> CROSS STREET 'J KC//�i NE PILIL + ' y.}� tAPN ©CS - 7--1 y I 1 PARCEL SIZE C)'4 - `rp <br /> tv <br /> OWNER NAME KU_I "1 C r IV-by N I f A-)� ""r � PHONE � �, �O �� Sn <br /> p 7 y <br /> OWNER ADDRESS 1 q.5%)`m_✓"( I `'Iy`t' (` CITY/STATE21P G�L✓T^� <br /> CONTRACTOR LlyIE U�"IZ GEoC�/v)Rl:r�1yY16rV3Y�L PHONE -3 ' &3 I <br /> CONTRACTOR ADDRESS 1-4o-I w• CITY/STATE/ZIP <br /> LICENSE i-!;'C-42 Ui::;C36 OTHER L� NUMBER 2(S I EXPIRATION DATEZ-- <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: _. NEW INSTALLATION _ REPAIR/ADDITION IENGINEER DESIGNED/ALTERNATIVE <br /> .... REPLACEMENT _. OUT-OF-SERVICE SEPTIC SYSTEM I] DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE U COMMERCIAL L 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 ft 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 It FOUNDATION ft PROPERTY LINE ft <br /> ❑ $UMP$ WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH It LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <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 /> MINIMU&JApdOUR AQ46ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 7 <br /> SIGNED TITLE 101LVJ' ✓N G IZ• DATE G- I - z-C <br /> L L <br /> C"%" <br /> MENT <br /> FI VED <br /> s JEA12020 <br /> E UlN <br /> DEPARTMENT U E ONLY PART ANI <br /> Application Accepted By-�� L L Date d aoc Area 11�t Employee ID#- ti1E <br /> Final Inspection By Date 20 Zd n SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# PermitID# <br /> Code INFO B Remitted Service Reauest# <br /> yaaa ra3 S7 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />