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CONTRACTOR ADDRESS <br />LICENSE C-42 0 DC-36 OTHER <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />/r4C-/ /11Ceh, <br />3-.S/Tite_e <br />Yetle5 <br />PHONE 3'/0 - <br />CITY/STATFJZiP 'Tr e-7/ C4.4 9 _C. <br />PHONE .:Zo -e7g--‘35/2- <br />vow/1 <br />'44 <br />v <br />ft n <br />0 <br />11 <br />Li <br />4-14 <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JoAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAzELToN AVENUE - STocKToN CA 95205 -(209)468-3420 <br />NON-REFUNDABLE PERMIT CALIr (209)953-7697 FOR INseEcnoNs EXPIRES 1 YEAR FROM DATE ISSUED <br />) 6; 55 sp IVY/ZIP e y 5.517zi 4/ <br /> aryisTATvzip L2 n 4 C ,4 y$'X' <br />NUMBER 1'77-7gEXPIRATIoN DATE 5 roA <br />APN <br />1 <br />l3 :]Y k:)3 PARCEL SIZE <br />WATER TABLE DEPTH: <br />PERC TEST # <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />BUILDING PERMIT* <br /> <br />LAND USE APPLICATION <br />TYPE OF WORK: C. NEW INSTALLATION <br />REPLACEMENT CI l< <br />REPAIR/ADDITioN <br />OUT-OP-SER <br />O ENGINEER DESIGNED lAtITERNATIvE <br />A DEsTRUcTioN fcip o <br />INSTALLATION WILL SERVE: <br />NUMBER OF LIVING UNITS: <br />0 co ERcIAL , d OTHER <br />NUMBER OF SEDROO s: 1., 1 \ J1,-.1 I NUMBER OF EmpLoYEEs: <br />la LIFT STATION <br />TYPE/MFG e We le 0 CAPACITY <br />CAPACITY <br />DISTANCE TO NEAREST: WELL k b /,‘ C--- ft FOUNDATION <br />SIZE TYPE OF UMP LI PKG TX PLANT <br />gal # OF COMPARTMENTS 4 -? IjY SEPTIC TANK <br />la GREqE TRAP TYPE/MFG gal # OF COMPARTMENTS <br />5 1 <br />ft PROPERTY LINE -2" ft <br />0 SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />CH LINES 0 LEACHING CHAMBERS <br />DISTANCE To NEAREST WELL <br />ID FILTER BED <br />WIDTH <br /> <br />ft LENGTH <br />DISTANCE TO NEAREST WELL <br />MOUNDED WIDTH <br />DISTANCE To NEAREST WELL <br />DI SUMPS WIDTH <br />DISTANCE TO NEAREST <br />LI DISPOSAL PONDS WIDTH <br />DISTANCE To NEAREST <br />SEEPAGE PITS NUMBER <br />DISTANCE To NEAREST WELL <br /> # OF LINES LENGTH OF LINES <br />ft FOUNDATION i .-1- ft PROPERTY LINE <br />DEPTH <br />ft FOUNDATION <br />6 <br />5.4- ft <br />WIDTH <br />ft LENGTH ft <br />ft LENGTH ft <br /> ft PROPERTY LINE <br />ft DEPTH <br />ft PROPERTY LINE <br />ft DEPTH <br /> ft FOUNDATION ft PROPERTY LINE ft <br />ft <br />ft FOUNDATION ft PROPERTY LINE ft <br />ft LENGTH ft DEPTH ft <br />ft <br />WELL ft FOUNDATION ft <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ft DEPTH ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED TFIIS 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 />MINIM 48 '(JR VANC NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 <br />DATE 0,2,4 2/ <br />A joP A QuYI:eivr <br /> S4N <br />FEB 1 6 2021 <br /> Reteverit <br />EATI, <br />YHIRD°IVMeTATTV EPARNENT HEA <br />p DEPARTMENT USE ONLY <br />Application Accepteg\By n Date ,f;1./(1g. Area .S.,; (.7 17 Employee ID# As 4— 4... <br />Final Inspection Bie f ,A...40^1 I Date IA U SPECIAL PERMIT -Approved by <br />it/Sump Soil Character: <br />(et CA Ctr r 4 9 <br />ekt <br />PE <br />Code <br />SC <br />INFO <br />Received <br />py, <br />Check <br />Cash <br />Amount <br />Remitted <br />....I.. <br />Date Permit/ <br />Service Request # Invoice /f Permit ID# <br />/..0 <br />e.i <br /> 26,, .9A QN, t''i.411)1 7-7t.•.; <br />Character of Soil to <br />c,OMM NT <br />‘•7 re ) <br />th are? Ft: . <br />1E4J-J2_ AJ2-;,A1 <br />4-p 6906 r-er t n' J24' <br />C ch.> <br />42-01 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18