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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 (:ALL <br />JOB ADDRESS //1 .3 v � <br />CROSS STREET v� / <br />OWNER NAME A & 6 A 1 /l (f,2 <br />JD.i-fD&f FOR INSIJbG I1UNZ:i r_AVIKtb I TtAK I-KUPA IJAIt IJJUtI <br />CITY/ZIP <br />APN -fl 9 0" 5 PARCEL SIZE <br />PHONE <br />OWNER ADDRESS �p CITY/STATE/ZIP <br />CONTRACTOR'}/� PHONE?`IP <br />/) .S ^% Jam^ S�^J� r <br />CONTRACTOR ADDRESS /G/ J l ���h �_ i ✓ `�� CITY/STATE/ZIP �y�� e-_ <br />LICENSE ❑f C-42 ❑11C-36 OTHER NUMBER3 EXPIRATION DATE ��� / 2`' 2 - <br />WATER <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION r l / REPAIR/ADDITION I I ENGINEER DESIGNED /ALTERNATIVE <br />'7X REPLACEMENT )fe-iL t I �7 3 }Ll I)F OUT -OF -SERVICE SEPTIC SYSTEM 0 DESTRUCTION 'k�j 11 k <br />INSTALLATION WILL SERVE: F RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: el NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br />El SEPTIC TANK <br />❑ GREASE TRAP <br />❑ LIFTSTATION <br />❑ LEACH LINES <br />id FILTER BED <br />❑ MOUNDED <br />Al <br />TYPE/MFG CAPACITY ( �c gal # OF COMPARTMENTS <br />TYPE/MFG l CAPACITY gal # OF COMPARTMENTS <br />J <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE S ft <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />WIDTH /2— ft LENGTH -30 ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />WIDTH ft LENGTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />SUMPS WIDTH ft LENGTH ft <br />DISTANCE TO NEAREST <br />DISPOSAL PONDS WIDTH <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION <br />ft LENGTH <br />WELL ft <br />FOUNDATION <br />ft <br />ft <br />ft PROPERTY LINE <br />ft <br />DEPTH 400j) c_ -_</C <br />ya ft <br />ft PROPERTY LINE <br />ft <br />DEPTH <br />ft <br />ft PROPERTY LINE <br />ft <br />DEPTH <br />ft <br />ft PROPERTY LINE <br />ft <br />DEPTH <br />ft PROPERTY LINE <br />❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <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 />SIGNED <br />ft <br />ft <br />ft <br />ft <br />TITLEJ.DATE <br />DEPARTMENT US ff ONLY <br />Application Accepted��B//,,yy,((►►.. Date W �% a / Area I % Employee ID# <br />Final Inspection By/► ��w /`1 Date LlSPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: PIUSum Soil Character: <br />COMMENTS { ���IC2✓Il�r1} d{ �tl�ir!A Sys-�'w �o�b�e dep.�h Jjj� 0kU4 per rfoa -4kvi <br />�TtA►'�cI�1 jy;i')wVM 911 ;Aches or i, k under f S -;l bb e w� e <br />11� <br />bL}r nt)t IPSS t�er0 % i'otbe< ­7�11 C, -r lP"i<h /ihes Nt' - �" .L." �'(IUe,7 aver; <br />PE <br />Code <br />Sc <br />INFO <br />Receive <br />Check#/ <br />Cash <br />Amount Date <br />Remitted <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />iia» <br />t l s <br />Sb <br />3v o 4211_1 <br />1V ONLIZO <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />