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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 />NUN-KEFUNDABLE PERMIT <br />JOB ADDRESS <br />CROSS STREET <br />C. <br />L@L'19M <br />'953-7697 FOR INSPECTIONS / -o/EXPIRES 1 YEAR FROM DATE ISSUE <br />0 L C <br />CITY/ZIP dd' (A- <br />t�L <br />APN 0 � 3 / f�'�y 1 fG PARCEL SIZE 1� , -3 b <br />OWNER NAME <br />.gro!2 <br />'/ P>) Iche r <br />PHONE <br />OWNER ADDRESS j//1�� 3y 1 <br />�o k6 Y (iL� <br />13 �/�)Y�)irh <br />i <br />io- CITY/STATE/ZIP { 0y� <br />%tel <br />l c O Lt <br />CONTRACTOR llr� R / <br />FILTER BED WIDTH ft LENGTH <br />�7 rC <br />PHONE �� / <br />i A <br />u / - S6o7 <br />CONTRACTOR ADDRESS <br />1-� [Q�/�l <br />3 / r 6 <br />/� <br />�l���h � CITY/STATE/ZIP <br />( <br />cJL�' C j (� Tsai 9 <br />LICENSE ❑ 42 ❑❑C-36 <br />OTHER <br />[/��ryP, <br />NUMBER_ TSyoy{E EXPIRATION DATE <br />DEPTH ft <br />WATER TABLE DEPTH: I oy - ) 1 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # a004 -10a LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />❑ REPLACEMENT —11 OUT -OF -SERVICE SEPTIC SYSTEM ElDESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL(14) <br />ElOTHER <br />OOMS: <br />NUMBER OF LIVING UNITS: 1 NUMBER OF BEDRNUMBER OF EMPLOYEES: <br />{�l SEPTIC TANK TYPE/MFG (04Cr?le /"Y C <br />❑ GREASE TRAP TYPE/MFG <br />DISTANCE TO NEAREST: WELL -3(50" <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />CAPACITY /&00 gal # OF COMPARTMENTS oZ <br />CAPACITY gal # OF COMPARTMENTS <br />ft FOUNDATION o'er 7 ft PROPERTY LINE Yy ft <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />J DEPARTMENT U E ONLY <br />Application Accepted By v Dateell? `r d i Area C Employee ID# AJA <br />Final Inspection By r ��%� Date !! ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS SPC4 S F12 1 &y <br />PE <br />Code <br />LEACH LINES ❑ LEACHING CHAMBERS <br /># OF LINES 3) <br />LENGTH OF LINES 80 , ft <br />Permit/ Invoice # Permit ID# <br />Request # <br />DISTANCE TO NEAREST WELL 300 / <br />ft FOUNDATION 30 <br />ft PROPERTY LINE L ft <br />❑ <br />FILTER BED WIDTH ft LENGTH <br />_ ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />SEEPAGE PITS NUMBER 3 WIDTH <br />4/ <br />T -z , I ft <br />DEPTH o,:S— / ft <br />DISTANCE TO NEAREST WELL 300 <br />ft FOUNDATION ADO <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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED <br />TITLE LOI�4 C,% <br />DATE <br />J DEPARTMENT U E ONLY <br />Application Accepted By v Dateell? `r d i Area C Employee ID# AJA <br />Final Inspection By r ��%� Date !! ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS SPC4 S F12 1 &y <br />PE <br />Code <br />SC Received <br />INFO B <br />Amount <br />Cash RemittedService <br />Permit/ Invoice # Permit ID# <br />Request # <br />ya)1 <br />il� <br />_a j s8y <br />*te <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />