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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-KEFUNDABLE PERMIT /� L:ALL (ZUJ) &0J-/bY1 FOR INSPECTIONS tXPIRES 1 YEAR FROM DATE ISSUE <br />JOB ADDRESS I' LO I 1 A <br />I DA "L CRY/ZIIP^ STZ) Citz"ri q S-2-1 S <br />CROSS STREET S (� LE� APN I O 3 ' 2 % I/ - O O pPARCEL SIZE 2. 4 -- <br />OWNER NAME -70V RZ <br />a AILJ(PHONE / 2.3 - 013-1 <br />OWNER ADDRESS S A 1,11 L- CITY/STATE/ZIP <br />CONTRACTOR U V I T ��//W O ArY- G-�o`E�VIRoNME"T)0lI _, PHONE 3195 `O'3 "1 <br />CONTRACTOR ADDRESS O 1 0■\ KT p S - CITY/STATEIZIP Lo t> ( C h r S7 Z''q Z) <br />LICENSE ❑i..IC-42 ❑IX -36 OTHER �Ccl- NUMBER Z) 5 ( EXPIRATION DATE 4 -3 O - Z2 <br />WATER TABLE DEPTH: <br />it GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />PERC TEST # <br />( BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />❑ NEW INSTALLATION ❑ <br />REPAIR/ADDITION <br />❑ ENGINEER DESIGNED/ALTERNATIVE <br />ft PROPERTY LINE ft <br />❑ REPLACEMENT El <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />o DESTRUCTION <br />INSTALLATION WILL <br />SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPEIMFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />I <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />0 LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TD NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />It LENGTH <br />It <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />It LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />It PROPERTY LINE It <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <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 />►TIGriLr�;l#lI�j�Cd tX�i►IL'7��7�1��� • •PL <br />L%TITLE DATE <br />DE PA RTMENTUS ONLY <br />Application Accepted By L/Z Date S Area LI n�� Employee ID# 1 <br />Final Inspection By Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />PE SC Received Check#/ Amount ate PBrmiU Invoice # Permit ID# <br />Code INFO Ca Remitted Service Re uest # <br />li��� t,� IS uuZ 2 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />TY <br />