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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(2009 953-7697 FOR INSPECTIONS 7,C-kEXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1033- 1 t1 S�• I -1 1 w I � c—v <br /> • CITY/ZIP 5 1 --rV­NJ <br /> CROSS STREET w PC LL-El-z' APN 12 Z--' U3O—OAC 2 <br /> {..,. f {' 1 /P-ARCEL SIZE <br /> OWNER NAME -t Ej1 ��i L'1 C1 I�0 I)�I6;V10 5C�,1"PH <br /> e ONE &41 <br /> OWNER ADDRESS /I��-q� �LI V S GT• p CITY/STATE/ZIP 1 UC'7K--1�N f CA 1 7-IO <br /> CONTRACTOR L-(Ut V' �W- ���V(��N roC&J YL PHONE �t0l-03 1 q <br /> CONTRACTOR ADDRESS ',�01 t-� ' K .ST-• CITY/STATE/ZIP L-CID ( C'"-I, / S <br /> LICENSE C1.':C-42 11PC-36 OTHER 6r NUMBER -kl 1 EXPIRATION DATE 130 "Z-Z <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 C_ REPAIR/ADDrnON G ENGINEER DESIGNED/ALTERNATIVE <br /> 11 REPLACEMENT I.1 OUT-OF-SERVICE SEPTIC SYSTEM U DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY 921 #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY 921 #OF COMPARTMENTS <br /> a 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 It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ FILTER BED WIDTH It 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 ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL It 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 It FOUNDATION ft PROPERTY LINE It <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 /> IN/M H 4 E NOTICEREQUIRED FOR INSPECTIONS-PLEA E CALL Q09)953-769 <br /> SIGNED TITLE PR-OJ &r2- . DATE 1U` 1 W <br /> t <br /> YMF�r <br /> F�VFO <br /> t_ 0 ,7020 <br /> � NC <br /> �-? TM <br /> O <br /> IJ <br /> Application Accepted By G �`L div D E P A R <br /> E N T Da eU,I � N L y Area �iX/]C`�/�� Employee ID# D <br /> Final Inspection By Date :7 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# Permit ID# <br /> Code INFO B / sh Remitted Service R uest# <br /> Lima S-a� gam- NS V11 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />