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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 GALL (ZUV) Yb3-/619/ FOR INSPECTIONS tXPIRES 'I YEAR FROM UATE ISSUEI <br />JOB ADDRESS7 71 <br />a/// / CITY/ZIPI <br />CROSS STREET /� /(�[brfGlJY�%L(� �(Je APN o� a `� 3 Li PARCEL SIZE /rte / U <br />OWNER NAME Div.; �%���C3/2C11� PHONE 614101- 71723/ <br />OWNER ADDRESS O I VI Vl I h l�Vj CITY/STATE/ZIP <br />CONTRACTOR y�PHONE :3��' VG.� <br />CONTRACTOR ADDRESS. t! J ///�y� r �i� CITY/STATE/ZIP <br />LICENSE E�&,-42 ❑ L C-36 OTHER NUMBER 17"0 `/s- EXPIRATION DATE 02 1-61 <br />WATER TABLE DEPTH: la -cX 0 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 SEPTIC SYSTEM I DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />❑ GREASETRAP <br />❑ LIFT STATION <br />TYPE/MFG 5 / S/7 eu/ CAPACITY <br />TYPE/MFG CAPACITY <br />DISTANCE TO NEAREST: WELL ft FOUNDATION <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />°ZLEACHING CHAMBERS azo_ <br />Received <br />By <br /># OF LINES <br />LENGTH OF LINES /UO / ft <br />Date <br />DISTANCE TO NEAREST <br />WELL , ov <br />ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />f3oa <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />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 />SIGNED <br />TITLE <br />DATE <br />-EPARTMENT USE ONLY <br />Application Accepted B Date o7L Area S Employee ID#or <br />+� <br />Final Inspection By Date 11 SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />rf <br />COMMENTS F4.I m� sxOem - 7i pr <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />2413 ;2,I <br />f3oa <br />z <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/16 <br />1 <br />r <br />