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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVFNI IF . Amey^., PA 0—Al , <br />NON-REFUNDABLE PERMIT ^ M CALL 209 953-7697FORINSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS ���'7 I'1 II IIl.r1� �q�yAM,� IOW CITY21P �Wrf <br />CROSS STREET ! P / II) ✓ E APN0`� Q/1 -- t `� PARCEL SIZE <br />OWNER NAME L'` Y✓pt Y r i,!—yf� G )'e h "d.), PHONE <br />112 C(j r, <br />OWNER ADDRESS i r r l c o 6, -ave _ CITY/STATE/ZIP "d.) <br />CONTRACTOR 04 jj,%CK4 .e r -,,-.PHONE ,,��I Q <br />CONTRACTOR ADDRESS '" L`)j�' ^ �`Z, CITYISTATE/ZIP -k `GJf of 4c,,s ,4 a t— <br />LICENSE 110C -42C-42 ❑/' DC -36 OTHER_ I - NUMBER L. AIS5LI EXPIRATION DATE <br />WATER TABLE DEPTH: C-" J O ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # �+CX3 �Il(81� LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION U REPAIR/ADDITION L I ENGINEER DESIGNED /ALTERNATIVE <br />n REPLACEMENT L3 OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: "ESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: 3 NIIMRFR n= F: G -- <br />Ur SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />DISTANCE TO NEAREST: WELL 1 1 <br />(3 LIFTSTATION SIZE TYPE OF PUMP <br />CAPACITY L rr). 30 gal # OF COMPARTMENTS <br />CAPACITY gal # OF COMPARTMENTS <br />It FOUNDATION 3"'.31 <br />ft PROPERTY LINE J.S-1 ft <br />. 13 PKG TX PLANT L) SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />ld LEACH LINES ❑ LEACHING CHAMBERS #OF LINES, 1 LENGTH OF LINES 4&Al ft <br />DISTANCE TO NEAREST WELL 1 C)01 ft FOUNDATION .�,5 t ft PROPERTY LINE +�_5- It <br />❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br />❑ MOUNDED WIDTH ft LENGTH ft DEPTH (( <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br />❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE ft <br />❑ DISPOSAL PONDS WIDTH it LENGTH ft DEPTH it <br />/� DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />a SEEPAGE PITS NUMBER . L WIDTH Lj a It ft DEPTH AS r ft <br />DISTANCE TO NEAREST WELL S -. I ft FOUNDATION —5E0±_ft PROPERTY LINE._ -S" It <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 ADrNCE NOTICE REQUIRED FOR INSPECTIONS, PLEASE CA / (209) 953-7697 <br />SIGNED I, ,(1tL.: o� TITLE G��( MP.- i i� DATE �3 <br />DEPARTMENT SE ONLY <br />Application Accepted y - Date V1112 a % Area I Gl-/ Employee ID# <br />Final Inspection ByDate 3 ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 F . PiUSump Soil Character: <br />COMMENTS Sf�L�rld cFP- %;Pr Z . N-'� VJP11.5yl,%61/n se4L</cks Pe"L D T S. <br />PE SC Received Check# Amount Date Permit/ Invoice # Permit ID# <br />Code INFO B Cash Remitted Service Request # <br />,,ail ('r /FZ& SNL m, <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4114/18 <br />I� <br />0 <br />R <br />