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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 209 953-7697FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS (01C)3 W- 7>LZ-TA AVC CITY/ZIP_-_-T-P A-C `t 3 0 <br /> CROSS STREET T I\ Z-r�h�l S E __. APN__ I_�_ PARCEL SIZE At <br /> o <br /> —_._._- <br /> OWNER NAME fte).j Ry Al A FR rI IQ _ _--_---PHONE <br /> i <br /> OWNER ADDRESS SA me / CITY/STATE/ZIP <br /> CONTRACTOR LIVELDAK GEDEn V1$Zo I"CAfAL- PHONE 3111, 071 S <br /> ��T <br /> CONTRACTOR ADDRESS o-7 Lo D PSK ST• CITY/STATEIZIP L.-DC�I CA Ct �•�0 <br /> LICENSE . C-42 C-36 OTHER C EU NUMBER ZI I EXPIRATION DATE L4_3O -22 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> A PERC TEST # Z BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE _. _.__ TYPE OF PUMP, ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft -ROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL h FOUNDATION ft PROPERTY LINE It <br /> ❑ SEEPAGE PITS NUMBER_ WIDTH A DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 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 /> MINl NOTICE REQUIRED <br /> ._ F INSPECTIONSALL 7 <br /> SIGNED TITLE � MDATE <br /> Z <br /> � I •` om JJI <br /> .�..Sa•' <br /> RK <br /> < <= <br /> iw 4 <br /> COIJ <br /> DEPARTMENT^ SE ONL Y - , �NT,� <br /> Application Accepted B C L Date S L/ Area L Employee ID# S �TMENT <br /> Final Inspection By f� � ?���Date Z SPE IAL PERMIT-Approved by <br /> Character Of Soil to Depth of 3 Ft: _ Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received C Amount Dffi Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> Llada Laz S-a raceco 33021 SAUV^ULQ <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14118 <br />