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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 />MON-KEFUNDABLE PERMIT GALL LUV VO:S-/bV/ FOR INSPECTIONS t_XPIRES 'I YEAR FROM UATE ISSUEI <br />JOB ADDRESS I Ll j Ll b" hi _t yL� CITY/ZIP <br />CROSS STREETI•• II hcr�I. AP^/�fi'w a�i� ��PARCELSIZE 1 V J <br />OWNER NAME 4 L) b /0 Q cri l✓) T v ,T PHONE <br />OWNER ADDRESS 1 <br />LI11-2-5- <br />A..'VA &b rk/ CITY/STATE/ZIP <br />CONTRACTOR V lI, y1S [ (,� { // �. PHONE <br />CONTRACTOR ADDRESS jo^ � � [i �:� CITY/STATE/ZIP w`na i.,,4 G/r <br />LICENSE 11❑C-42 ❑11C-36 OTHER NUMBER 66A EXPIRATION DATE_ <br />WATER TABLE DEPTH: 1 I D j ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT#ai.)bdo SZ�: 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: 04RESIDENCE ❑ COMMERCIALEl OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: 'Ir '9 NUMBER OF EMPLOYEES: <br />15 -`SEPTIC TANK <br />TYPE/MFG qe d'L <br />CAPACITY 10 a j� gal <br /># OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal <br /># OF COMPARTMENTS <br />S -0L <br />DISTANCE TO NEAREST: WELL <br />r <br />ft FOUNDATION by I ft <br />PROPERTY LINE to I ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES ❑ LEACHING CHAMBERS <br />❑ FILTER BED <br />❑ MOUNDED <br />❑ SUMPS <br />DISTANCE TO NEAREST <br />WIDTH <br />DISTANCE TO NEAREST <br />WIDTH <br />DISTANCE TO NEAREST <br />WIDTH <br />DISTANCE TO NEAREST <br />❑ DISPOSAL PONDS WIDTH <br />DISTANCE TO NEAREST <br />ILF� SEEPAGE PITS NUMBER_ <br />DISTANCE TO NEAREST <br />WELL ft <br />ft LENGTH <br />WELL <br />ft LENGTH <br />WELL <br /># OF LINES <br />LENGTH OF LINES �7J ( ft <br />FOUNDATION t ft PROPERTY LINE to 1 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 LENGTH ft DEPTH ft <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />ft LENGTH ft DEPTH ft <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />WIDTH 3G I► ft DEPTH acft <br />WELL Se ft FOUNDATION In ft PROPERTY LINE I(� I 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 />MINIMUM 48 HQU13 ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED TITLE �� (CCS 6 DATE�� <br />DEPARTMENTU E ONLY <br />Application Accepted ByDate 31 , j Area LI Employee ID# tJ <br />Final Inspection By Date MEN ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS Lrnp{oyfe {�a.. n� unl� �,pr 60 If,,6 111nP Sdr � �,e Pei 1)ed <br />0� be wY►d?r (',PiJIl.1P_ l� , jcA�KTVD or f'nG,rJW' C•V <�rL'i�U✓e, <br />PE <br />Code <br />SC <br />INFO <br />Received QCheck#/ <br />B as <br />Amount <br />Remitted <br />Date Permit/ Invoice # Permit ID# <br />Service Request # <br />Nd <br />11-7 <br />S -0L <br />3121 S 00�yIlQ(p <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />