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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 Z YEAR FROM DATE ISSUED <br />JOB ADDRESS 1H��5 Gr,C f- P /,CA CCIIT/YIZIP / 4 h L <br />1 <br />CROSS STREET A%VL('I ,�J 4 APN /01- 0O0 C) PARCEL SIZE <br />OWNER NAME PHONE <br />OWNER ADDRESS CITY/STATE/ZIP <br />1 <br />CONTRACTOR L .��[,f $«/�(( �/s� �Q� ; PHONE <br />CONTRACTOR ADDRESS P'S -'y l�?'IwnCITY/STATE/ZIP c� �. 11< � G✓� <br />LICENSE ❑IIC-42 11FIC-36 OTHER —& NUMBERf// OQ6_S� EXPIRATION DATE <br />WATER TABLE DEPTH: jU r �U ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION 1_I ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT 11 OUT-OF-SERVECE SEPTIC SYSTEM I1 DESTRUCTION <br />INSTALLATION WILL SERVE: &-<ESIDENCE 11 COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES 7 LEACHING CHAMBERS #OF LINES LENGTH OF LINES 46/ ft <br />DISTANCE TO NEAREST WELL _ C $13 ft FOUNDATION M PROPERTY LINE Ja I! ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />Date Permit/ Invoice # <br />Service Request # <br />Permit ID# <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />fl PROPERTY LINE ft <br />SEEPAGE PITS <br />NUMBER I -')-WIDTH <br />3c. tl <br />ft DEPTH X51 1 ft <br />DISTANCE TO NEAREST <br />WELLJ.,'5b 0 ft <br />FOUNDATION <br />ft PROPERTY LINE �[�l 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 />SIGNED <br />Application Accepted <br />Final Inspection Bye <br />Character of Soil to,D <br />COMMENTS //1 <br />VIN 11yJr.Cl1l /VIyo - rL1zM0z VHL4. 16VJ/ JJJ-/VUI <br />TITLE G-7✓1 it f DATE IIT — 11 <br />D IPARTMENT USE P N L Y <br />Date 17 �7r, Area Employee ID#� <br />Date c(/ ❑ SPECIAL PERMIT - Approved by <br />of 3 Ft: Pi /Sump Soil Character: LU4"A LUtW"" <br />PE <br />Code <br />SC <br />INFO <br />Received (CheSW <br />B shy <br />Amount <br />Remitted <br />Date Permit/ Invoice # <br />Service Request # <br />Permit ID# <br />p <br />42-01 <br />4/14/18 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />