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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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 9S H!�lTCH/,JSD�t/ RD. CITY/ZIP /nAN7-IECA 95337 Z <br /> CROSS STREETr kS T/� APN PARCEL SIZE C;?-7.9 <br /> v <br /> OWNER NAME !-/�Q,sTD1�NER VAN ! C,Riq 1667EAI PHONE aPf- 02- 7108 <br /> OWNERADDRESS/+L98'S1 NG/TCN/n�So/J RIS• CITY/STATE/ZIP er7ANr a /'Ag!-,3,37 <br /> CONTRACTOR C..HC-59f� Cnj5/ i-tiNSC PHONE <br /> CONTRACTOR ADDRESS P-D ox �37'?4 CITY/STATE/ZIP T-GI RLo c-VI CA !253A I <br /> LICENSE ❑I IC-42 ❑I 1C-36 OTHER 'gGL NUMBER�5�7� EXPIRATION DATE--./, A"IAOaZ& <br /> W ER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # / BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I I NEW INSTALLATION REPAIR/ADDITION i I ENGINEER DESIGNED/ALTERNATIVE <br /> I I REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I I 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 ft 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 ft 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 PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> HEREBY CERTIFY AT 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 /> MI 48 DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953 7697 <br /> SIGNED TITLE 6110- ! N�-INEE e DATE -7o <br /> -zq ho <br /> A J <br /> ZA R o <br /> D P A <br /> i <br /> EPARTMEN US ON Y <br /> Application Accepted By Date1/ Area Employee ID# <br /> Final Inspection By Date ❑ SPE AL PERMIT-Approved by <br /> Character of Soil to epth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS YlG tV 066. 7 ";07>S. <br /> PE SC Received hec Amount Permit/Code INFO B Cash emitted Date Service Request# Invoice# Permit ID# <br /> ON ro 1 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />