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If <br />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 HERMIIT <br />JOB ADDRESS / a ( <br />CROSS STREET Tea, I <br />OWNER <br />�yybJ-IDYI FOR INSPECTIONS CXPIRES "I TT FAR FROM UATE ISSUEI <br />CITY/ZIP ql O <br />_ APN O O 2 ` PARCEL SIZE <br />PHONE <br />OWNER ADDRESS L �/f CITY/STATE/ZIP 7 r7 <br />CONTRACTOR �/iit!! R L�Va/4 L)ZiI/Q�'�C PHONE (Jo �� _ �� r/�2�dc / <br />CONTRACTOR ADDRESS l A;47 1 - '� '1//_ L CITY/STATE/ZIP <br />LICENSE ❑C�-42 ❑LIC -36 OTHER NUMBER 7� O L EXPIRATION DATE <br />WATER TABLE DEPTH: if'/ ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # AND USE APPLICATION ## <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I I ENGINEER DESIGNED /ALTERNATIVE <br />LI 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 />11 <br />ASEPTIC <br />❑ <br />❑ <br />TANK <br />GREASE TRAP <br />LIFT STATION <br />TYPE/MFG 4g,16.c 7e- // /y C. <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL 15-01 / <br />SIZE TYPE OF PUMP <br />CAPACITY ���U gal # OF COMPARTMENTS <br />CAPACITY gal # OF COMPARTMENTS <br />ft FOUNDATION ft PROPERTY LINE zO / <br />❑ PKG TX PLANT ❑ OIL SEPARATOR (ENCLOSED SYSTEM) <br />ft <br />LEACH LINES <br />LEACHING CHAMBERS <br />,SAND <br /># OF LINES / <br />LENGTH OF LINES SS / <br />ft <br />DISTANCE TO NEAREST <br />WELL S6 / ft <br />FOUNDATION �J ! <br />ft PROPERTY LINE S / <br />ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />It <br />❑ <br />SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />I <br />PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft ;PROPERTY LINE <br />ft <br />If <br />SEEPAGE PITS <br />NUMBERrj. <br />WIDTH [{7 <br />l' <br />ft <br />DEPTH <br />ft <br />DISTANCE TO EAREST <br />WELL /So ' ft <br />FOUNDATION 80 <br />ft PROPERTY LINE L <br />ft <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 />Irnrvnnvrn Yo nvvrx tiUvril I-wn IIYJrC�^V I I/V'/Yo -- r-LCMJc %.Mcc cva aua-I Var <br />SIGNED - TITLE Co�,lYy(/Z�— DATE l2 <br />`op ♦ . <br />LLW <br />1 SENT U E'ONLY <br />Application Acceptedy Date l Area T( `i Employee ID# r/ <br />Final Inspection ByItLV Date61 7/ C SPECIAL PERMIT - Ap <br />Character of Soil to Depth of Ft: Pit/Sump Soil Character: _ . _ <br />COMMENTS ZU2i rrYI�A <br />uta o <br />PE SC Received (gLeckV <br />Code INFO B Cash <br />Amount <br />Remitted <br />Date <br />Permit/ RO MEN ID# <br />In <br />Service Request # <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />