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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 'I YEAR FROM DATE ISSUED <br /> CITY/ZIP /IsJ��i `f <br /> JOB ADDRESS <br /> CROSS STREET /v�l� /s;C%`�� APN D 1 /(9(l 03V PARCEL SIZE <br /> z <br /> &ecv res��►"'i PHONE <br /> OWNER NAME - ? <br /> OWNER ADDRESS ��,�jCITY/STATE/ZIP <br /> �j / <br /> CONTRACTOR VVA1-4I �jVVI ^ i PHONE O"f 21� <br /> CONTRACTOR ADDRESS -- CITY/STATE/ZIP -.rAc <br /> LICENSE ❑[ 42 ❑11C-36 OTHER NUMBER ��/ EXPIRATION DATE <br /> WATER TA13LEE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ' ( ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT MIn 3 C el� El OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION IC4Ak <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ] ❑ OTHER <br /> NUMBER OF LIVING UNITS: pNU>MBER OF BEDROOMS: 65/ NUMBER OF EMPLOYEES: <br /> x r <br /> SEPTIC TANK TYPE/MFG la�lc/ /.3 (r CAPACITY 140© _ gal #OF COMPARTMENTS_ <br /> 0 GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL_/1:dU ft FOUNDATION—_100 ft PROPERTY LINE IOo ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT LI SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ft <br /> x LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES Ss <br /> DISTANCE TO NEAREST WELL ft FOUNDATION Z40 ft PROPERTY LINE ft <br /> 10 FILTER.BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> D 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 /> XSEEPAGE PITS NUMBER_ J WIDTHya ft DEPTH d� ' ft <br /> DISTANCE TO NEAREST WELL O ft FOUNDATION Ay 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL (209)953-769�7J <br /> SIGNED A6n /�G/ TITLE LON �i DATE 7- <br /> ,or0a7 <br /> --- ' <br /> .j <br /> LIP <br /> O <br /> OOrzh <br /> , <br /> / DEPARTMENT {JS ONLY <br /> Application Accepted B G v Date_ 0'pv Area qel Employee ID#L <br /> Final Inspection By Date 177Z,0 SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump So11 C aracter: <br /> COMMENTS Vii s 54P►^'► �r I• ��c,X))-0 um sal I ("OW' ' L3 Joe r"vTP M4 yl <br /> a )1 <br /> C1 ct C 0s,t io� Fq <br /> PE SC Received ec Amount Date Permit) Invoice#W Permit ID# <br /> Code INFO By Cash Remitted Service Request# <br /> g a I a 1201-20 00929,01 <br /> 42-01 I ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/16 �`� •r C ro ",I �C 4 � V' 0_�,*a C�V'", S <br /> DIG -���, � �� c���ii-�,-� -�-�� <br />