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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 <br /> /PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS �M*1Q GAtJE CITY/ZIP 5;_r0Cr0A1 9,5A/5 v <br /> H <br /> CROSS STREET WA7 E FZLOO APN Al I-D 22- PARCEL SIZE <br /> OWNER NAME_4�1r_ •r7'�AI. CI-A ncET 7TVTi— Hou ]C RekCL6 I ' ;44`'UAP O E Av9-44?S-,s/4 2 v� <br /> ,v�- Cn <br /> OWNER ADDRESS 3737 A/- C'N r/1g$A nl D CITY/STATE/ZIP ) 1 OG knoAI. rA <br /> /� <br /> CONTRACTOR l 149 SIV f y CO /V SU L 7-/A/,/7 PHONE �O�J� �D Z J�►Sid <br /> CONTRACTOR ADDRESS P• O - 0o y}� 3 cl CITY/STATE/ZIP Tb RL o c,1! CA 01�-3g l <br /> LICENSE ❑❑C-42 1111C-36 OTHER /<C NUMBER ('75 4-79 EXPIRATION DATE G /10 Zg 0 <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 ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEI TIC SYSTEM ❑ 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 gal #OF COMPARTMENTS <br /> ❑ GREASE T RAP 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 /> ❑,R FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> Q-1 MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Ea SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> G@ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 0 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 /> MIN/ M 48 H ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL (209)953-7697 <br /> SIGNED TITLE elyIL "/46Eb.2 DATE3/TA-P <br /> MR <br /> 'r f <br /> O <br /> DEPARTMENT USE O LY <br /> Application Accepted Date j Area R Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Dep h of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS ?� �-tL ✓ ��S /I�n ,� <br /> r <br /> PE SC Received ckAmount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> tfiZL 523 [ ~2. '10'103P <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />