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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 p GALL ZDJ\\'Jb3-769/ FOR INSPECTIONS tXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS 2-3-70-2- A! . UI=V taf-A� IL• V —CITY/ZIP A -r A- I -fa 51-2-2-o <br />G A _ <br />CROSS STREET ✓%t�NT I, r APN 007 ' /�Q- OI �PIARCELSIZE It24e Ac. <br />OWNER NAME T(ZAC y GL. D ('t�'� Q1 y j PHONE I � � O� I <br />OWNER ADDRESS S/k�C -- I•V Q)�/1 ICITY/STATE/ZIP L-"Je Gf-ol Cjk qS a37 <br />CONTRACTOR LIVE DAV- 6-E0EAJVItej),y W CAIT A L_ PHONE 34ol —0371 <br />CONTRACTOR ADDRESS 'YO -7 lam! • D r IrK .5"r - CITY/STATE/ZIP I -O4-30-2-2- <br />DI C -A <br />LICENSE -;.'. C-42 ❑'.'. C36 OTHER cecr NUMBER 2I S I EXPIRATION DATE <br />WATER TABLE DEPTH: <br />ft 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 />It DEPTH It <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL SERVE: J 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 />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <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 />LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />D e Permit/ Invoice # Permit ID# <br />Service Request # <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />It DEPTH It <br />F -T - — <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE It <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />it DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE It <br />❑ SUMPS <br />WIDTH <br />It LENGTH <br />It DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />It LENGTH <br />It DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION It PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE 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 <br />OUR ADMANCE NOTICE <br />E <br />1 EDF R INSPECTIONS - PLEASE CALL (209)- 7 <br />SIGNED <br />TITLE P" • M62 DATE /D—I6--2I <br />= er VELLA <br />1 ' i <br />PAYMENT <br />ECEIVED <br />T 18 2021 <br />DEPARTMENT US&ONLY SAN JOAQUIN COUNTY <br />Application Accepted B Date / ( Area Employee ID# <br />SAN <br />Final Inspection By /ny/ I CO (Sq +�/� •'Z Date I��I �VZ SPECIAL PERMIT -Approved by NEA TH DEPARTMENT <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />PE <br />Code <br />Sc Received Check#/ <br />INFO h <br />Amount <br />Remitted <br />D e Permit/ Invoice # Permit ID# <br />Service Request # <br />a <br />sa3)114 <br />-GD e <br />i ul 19 14 S <br />F -T - — <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />