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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 />INUN-MittUNUAtSLt F't/K/M� IT At-)& <br />CALL (ZUy) Y53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE <br />JOB ADDRESS � P; a LA 1lATor� U & r CITY/ZIP '3 ��1—��i �< <br />5 '-> Y <br />CROSS STREET �yc V APN I 7 - f ^' 5.�� '©�� PARCEL SIZE <br />1 dIds <br />- <br />OWNER NAME � 4j if Q �/, 1/4 J) I' PHONE Qy / ^ 9-7/-2-94- <br />OWNER ADDRESS 2 75 �%i I/J2AQ..�Lfc� CITY/STATE/ZIP C(_1:_4 C <br />CONTRACTOR L//A4 f%CG�ii�'j PHONE <br />CONTRACTOR ADDRESS <br />LICENSE ❑' C-42 ❑ I C-36 OTHER <br />CITY/STATE/ZIP <br />NUMBER EXPIRATION DA <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED /ALTERNgTiVE <br />REPLACEMENT j I OUT -OF -SERVICE SEPTIC SYSTEM A DESTRUCTION s('� J IG f(lft <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />1 <br />❑ SEPTIC TANK <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />ft <br />CAPACITY <br />CAPACITY <br />FOUNDATION <br />❑ PKG TX PLANT <br />❑ <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />It PROPERTY LINE <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />ft <br />❑ LEACH LINES <br />I LEACHING CHAMBERS <br />079 <br /># OF LINES <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />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 />SIGNED <br />VPC 11yar-Cf-IIV/YJ - P-LCHJC C..HLL ILV71 7uo-I V7/ <br />TITLE / [��✓ DATE <br />a <br />DEPARTMENT USE ONLY <br />Application Accepted By C��� Date off$ O Area I 5fjC4Jl1 Employee ID# SK <br />Final Inspection By Date ( ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS L P i�Pnt(' IS o lopce1" h, hGr►'Cf'I uc ��1 IPs �� bCi i Pvjer' <br />ex TP;lC�eL i1 F Pct roG�G1 LP ) SS UC' )qp; rPs l'1 O S— /. Gly Com! <br />Iyl �0 e fPc U/' C �''��� d l <br />PE <br />Code <br />SC <br />INFO <br />Received Chec <br />Bv ash <br />Amount <br />Remitted <br />Date <br />PermiU <br />Service Request # <br />Invoice # <br />Permit ID# <br />4aa <br />079 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />