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lo <br />U <br />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 CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />77 <br />JOB ADDRESS f` d CITY/ZIP ; r C "i- q� 2� I <br />CROSS STREET COO (/ P rn L�(t �— APN t1 [�� ZZ V I PARCEL SIZE <br />OWNER NAME T%/`'�tJ /1 `D / / l JV�n`/�' PHON <br />OWNER ADDRESS <br />, �C <br />ITY/STATE/ZIP <br />CONTRACTOR "-L,2 W6-1 ' o" L PHONE L709)6,J�l �/N,�2! 7�2 <br />CONTRACTOR ADDRESS //dV-\AiACITY/STATE/ZIP st <br />LICENSE LI -C -42-C-42 ❑'C-36 OTHER C✓ f�} <br />( 9 NUMBER �Od Sy �� EXPIRATION DATE 0 r . -�2Q � <br />I'V — IO <br />Sc <br />INFO <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />Amount <br />Remitted <br />❑ PERC TEST # BUILDING PERMIT #__I %O �L �I 3 �­, LAND USE APPLICATION # <br />Permit/ <br />Service Request # <br />TYPE OF WORK: NEW INSTALLATION I REPAIR/ADDITION I ENGINEER DESIGNED /ALTERNATIVE <br />Permit ID# <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION <br />INSTALLATION WILL SERVE: &'f ESIDENCE ❑ COMMERCIALEl OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 4 NUMBER OF EMPLOYEES: <br />oU 13 <br />j 2 <br />❑ SEPTIC TANK TYPE/MFG � L- CAPACITY 00 gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />2 <br />DISTANCE TO NEAREST: WELL ( / ft FOUNDATION ft PROPERTY LINE <br />J -- <br />ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />l7 LEACH LINES I LEACHING CHAMBERS # OF LINES J LENGTH OF LINES D U / <br />ft <br />DISTANCE TO NEAREST WELL I ft FOUNDATION 5 ft PROPERTY LINE 270 <br />ft <br />❑ FILTER BED WIDTH ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ MOUNDED WIDTH ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SUMPS WIDTH ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH <br />f{ <br />/ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />/' <br />ft <br />_ <br />UJ' SEEPAGE PITS NUMBER WIDTH 9 ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL �?- )- Z ft FOUNDATION 10 Z 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 />MINIM M 48 HOM4QVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-769 <br />SIGNED 1 TITLE (9),V,, Vl DATE h - / 0 — 202 L <br />�-'DRTMEN US ONLY <br />Application Accepted By Datd5;—' Area Employee ID#� <br />Final Inspection By N • Dateb Z ❑ SPEC AL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />PE <br />Code <br />Sc <br />INFO <br />Received Check#/ <br />B Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />z� <br />6,1 <br />oU 13 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />Z <br />r' <br />v <br />c <br />z <br />J <br />'n <br />