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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 L:ALL (ZU9) 953-11597 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSL <br />JOBADDRESS 1 y51 uCrV,uDopiz C CITYRIP Ac.yrrrnpo I9s-27-0 <br />CROSS STREET � .i,I U 1 / APNDD 7-170 - O !1 PARCEL SIZE_ <br />OWNERNAME PHONE <br />OWNER ADDRESS%(�%�N?!t -7- CITYISTATEI JP <br />CONTRACTOR ✓) '-ONJS rx" TttlY✓ 3 S -+'TTS . PHONE �/ �L�� L Z 1 .Q'7 <br />CONTRACTOR ADDRESS F-5-7) 7-70AfrCo— eACek J2 too p CRY/STATEIZIP SRI-/�-hMf/Y.v L?�±Z % S 2 <br />' d <br />LICENSE IL : 42 C-36 OTHER NUMBER / ZZ y 3 �� EXPIRATION DATE (-C/1 n/Z O L Z - <br />WATER TABLE DEPTH: <br />PERC TEST # <br />TYPE OF WORK: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />BUILDING PERMIT # LAND USE APPLICATION # <br />NEW INSTALLATION REPAIRIADDITION ENGINEER DESIGNED IALTERNATNE <br />REPLACEMENT Nk E'it OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION ta) SCAM <br />INSTALLATION WILL SERVE: RESIDENCE <br />COMMERCIAL OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: <br />73 NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG Clrt/«ft <br />CAPACITY �7� gal #OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION R PROPERTY LINE ft <br />13LIFT STATION <br />TYPE OF PUMP <br />13 PKGTXPLANT 11 SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />CI LEACH LINES <br />,IZSIZE <br />I/ LEACHING CHAMBERS �f �'� <br />#OF LINES 3 LENGTH OF LINES -5 Y I It <br />DISTANCE TO NEAREST WELL /CC <br />ft FOUNDATION yO It PROPERTY LINE PF' ft <br />❑ FILTERBED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION ft PROPERTY LINE R <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH It <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE It <br />❑ SUMPS <br />WIDTH It LENGTH <br />ft DEPTH It <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE R <br />❑ DISPOSAL PONDS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />� // <br />F� SEEPAGE PITS <br />NUMBER 3 WIDTH <br />'lZ' ft DEPTH 2S 1 It <br />® <br />DISTANCE To NEAREST WELL 159' ft FOUNDATION / O ' ft PROPERTY LINE 5 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 />,MINIMUM48 <br />SIGNED <br />h1quR ADVANCE NOTICE REQUIRED <br />FOR INSPECT7QNS -PLEAS CALL (209) 953-769 <br />TITLE Pe 6; 'b IL DATE L- 2",'-/ <br />PAYMENT <br />RECEIVED, <br />SEP 202021 <br />,AN JOAQUIN COUNLy. <br />UNVIONMENTAL <br />tif" 11�DC ARIMEW <br />Character of Sol] �toiDepth of 3 Ft: PIUSump Soll Character: <br />COMMENTS I if- ZIP ' e' five LICS tOy�L� - (v <br />I " `" "" ""' I Date I """" I Invoice # I Permit ID# <br />INFO .Bv /� Remitted I f Service Request # <br />42-01 �'I . �`�� Ili ,.4- 1 � / I , L% %n�SITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4114118 T/ l II s�V <br />