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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
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<br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED
<br />JOB ADDRESS 1 7 i iu
<br />CROSS STREET \A) v
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<br />APN 11 LI 00 PARCEL SIZE
<br />OWNER NAME F. -,.. ia 10 1a..1 s tv
<br />OWNER ADDRESS I 6,3 9 N A tp) Aye.. fa Cm/STATE/ZIP 614-12,11. /CA I
<br />PHONE qi&,— 366 - I 11
<br />CITYISTATE/ZIP 10) 14-or c-Azi 956q3
<br />LICENSE ! I C-42 i I C-36 OTHER NUMBER I Oh KOEXPIRATION DATE go I -e-C) Z.7
<br />PHONE 6 So o-szEs-
<br />CONTRACTOR 5 etifi 5e ro c 6 izoi-cp
<br />CONTRACTOR ADDRESS Po is e) X56 9
<br />PERC TEST #
<br />ENGINEER DESIGNED 'ALTERNATIVE ,
<br />/ DESTRUCTION t‘)'; £i, ,,(:J
<br />A RESIDENCE I • • COMMERCIAL I ' OTHER
<br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: j. ( ,fit, 3,1 Cil ,v,e(1 NUMBER OF EMPLOYEES:
<br />A SEPTIC TANK TYPE/MFG P I I-- CAPACITY 1 2 Oc gal # OF COMPARTMENTS
<br />0 GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTNIENTS
<br />DISTANCE TO NEAREST: WELL --)-(- : ft FOUNDATION 7 `-) ft PROPERTY LINE -77 ( ft LIFT STATION SIZE TYPE OF PUMP U PKG TX PLANT U SAND OIL SEPARATOR (ENCLOSED SYSTEM)
<br />INSTALLATION WILL SERVE:
<br />TYPE OF WORK:
<br />WATER TABLE DEPTH: 0 — ft
<br />NEW INSTALLATION
<br />X fft rt lc ( t
<br />REPAIR/ADDMON
<br />REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM
<br />BUILDING PERMIT*
<br />
<br />LAND USE APPLICATION
<br />GEOGRAPHICAL INFORMATION: Coordinates X
<br />2 DISTANCE TO NEAREST WELL I C- ft FOUNDATION _6-) c . _ . . _ . . .
<br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK voLL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,
<br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY.
<br />
<br />MINIMUM 4 UR DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697
<br />SIGNED TITLE C;;" DATE c— I S' &' Z-
<br />DISTANCE TO NEAREST
<br />FILTER BED WIDTH ft LENGTH
<br />DISTANCE TO NEAREST WELL
<br />MOUNDED WIDTH ft LENGTH
<br />DISTANCE TO NEAREST WELL
<br />SUMPS WIDTH ft LENGTH
<br />DISTANCE TO NEAREST WELL
<br />DISPOSAL PONDS WIDTH ft LENGTH
<br />DISTANCE TO NEAREST
<br />SEEPAGE PITS NUMBER t'.)•
<br />LEACH LINES ' LEACHING CHAMBERS
<br />WELL 7 0 ft FOUNDATION /00 4-- ft PROPERTY LINE / 0 ft
<br /> ft DEPTH ft
<br />ft FOUNDATION ft PROPERTY LINE ft
<br /> ft DEPTH ft
<br />ft FOUNDATION ft PROPERTY LINE ft
<br /> ft DEPTH ft
<br />ft FOUNDATION ft PROPERTY LINE ft
<br /> ft DEPTH ft
<br />WELL ft FOUNDATION ft PROPERTY LINE ft
<br />WIDTH 3 C' " ft DEPTH S' ft
<br /># OF LINES LENGTH OF LINES ft
<br />ft PROPERTY LINE 0 ft
<br />SAN
<br />DEPARTMENT UST ONL Y
<br />Application Accepted e•-..7--:- 7:2- 4/,____
<br />Date .;//c/,... ; Area 11 /Cie% Employee ID#
<br />Final Inspection By ----"J"'"------\,.._ _.....---Date ,,, /
<br />Character of Soil to DeDepth of,3 Ft:
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<br />u Soil
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<br />\ , SPECIAL PERMIT - Approved by
<br />Pi Soil Character:
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<br />Code
<br />SC Received
<br />INFO By
<br />Check#/
<br />Cash
<br />Amount
<br />Remitted Date Permit/
<br />Service Request # Invoice # Permit ID#
<br />N7 7-6 VI:d1 --fc) 2.11 ,11 S2.0023'500
<br />42-01
<br />4/14/18 12.obuiv-tot ONSITE WASTEWATER TRTMNT SYSTEM PERMIT
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