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0 <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-KEFUNDABLE PERMIT <br />GALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS -5-0' <br />j '1 <br />h X 14 <br />CITY/ZIP �Gt.�c L'�) `� <br />4 - <br />CROSS STREET <br />ZGZA."c-'e <br />sw APN <br />(J ��/�� PARCEL SIZE <br />L <br />OWNER NAME <br />/�� <br />/G>� r µ+ms <br />PHONE <br />Z <br />OWNER ADDRESS <br />IJ v/\ <br />^y // <br />i (^ <br />]�UC���b GI <br />CITY/STATE/ZIP i /1 E. <br />1 C S <br />CONTRACTOR <br />ii� <br />��'� Sc-" �� - <br />PHONE <br />CONTRACTOR ADDRESS <br />FOUNDATION <br />CITY/STATE/ZIP <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />LICENSE ❑2,C,42 ❑' C-36 OTHER <br />NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: Z NUMBER OF EMPLOYEES: <br />L <br />SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY / C gal # OF COMPARTMENTS <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINESN <br />[I LEACHING CHAMBERS <br />Received <br />B <br />heck/ <br /># OF LINES <br />Date , <br />LENGTH OF LINES ft <br />1po a " " <br />DISTANCE TO NEAREST <br />WELL <br />%Lk:,' r <br />ft <br />FOUNDATION 04:1 ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ $UMP$ <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />DISPOSAL PONDS <br />WIDTH 2 <br />ft <br />LENGTH <br />�%-'00 <br />ft <br />DEPTH IS / ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />- %A 1 E-"eE-PIF$----1J11MBER <br />" r' <br />ft <br />DISTANCE TO NEAREST <br />WELL_ <br />/ ,"2 " <br />ft <br />FOUNDATION <br />ft PROPft <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 />DEPARTMENT SE ONLY <br />Application Accepted By A/� L Date 12 JF4 "' % Area �f� Employee ID# �v <br />Final Inspection By I_ wws�(_ Date Z 1� El SPECIAL PERMIT -Approved by <br />Character of Soil to Depth Pit/Sump Soil Character: <br />COMMENTS OT' /�)C)CL IF•`!7 /o Cc-�Idin of <br />tci v1 � r�� �Fer<�,,,, /r,c T pi: >'m ! } n n fPc. Yt� /3/iG ?_ai ,�.tf:/i� SGT' �0 7n � �✓L /,..lam <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />heck/ <br />Amount <br />Remitted <br />Date , <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />T <br />