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a <br />L <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// ALL 209 953-7697 FOR INSPECTIONS EXPIRES <br />1(JYEAR FROM DATE ISSUE <br />JOB ADDRESS .' 1 Z cl s 6 { CITY/ZIP � �� /YJ (l v <br />CROSS STREET X5 �, i U_ _ / ( APN I S 1 � 1 c� � � PARCEL SIZE � <br />OWNER NAME � i', C tC V `� e/ ( C Lei / PHONE <br />OWNER ADDRESS � L, 117/ ! 'y" 5 5—o .S-- S 1� CITY/STATE/ZIPIPW ?J -2G)_ <br />CONTRACTOR -e_C (. PHONE 20 Cl G0 1 L' <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE 11fJC-42 ❑CIC -36 OTHER NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: ft <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPJ (CATION # <br />TYPE OF WORK: IJ NEW INSTALLATION REPAIR/ADDITION ;A— <br />NGINEER DESIGNED /ALTERNATIVE <br />IJ REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION }� i,l K <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG CAPACITY <br />❑ GREASE TRAP TYPE/MFG CAPACITY <br />DISTANCE TO NEAREST: WELL ft FOUNDATION <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />L <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br />Permit/ Invoice # Permit ID# <br />Service Request # <br />LjdJ ) L-)_75 <br /># OF LINES <br />()%':5( <br />LENGTH OF LINES <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />❑ DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />1 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 />Vr% IIYJrCL, I IVI11J - r-LC/iJC l./1LL I LV.Y/ UUJ-/ V.Y/ <br />TITLE 8 L'41 X' tl-- DATE ✓�- `I)_ Z <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />Final Inspection By v� 't�iC r Date,�Z �! ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS Sfeel f4_ -, u 1R_-, rami, lel!( ° [a CT'_ <br />PE Sc <br />Code INFO <br />Received Check#/ Amount Dat <br />By Cash Remitted I <br />Permit/ Invoice # Permit ID# <br />Service Request # <br />LjdJ ) L-)_75 <br />0 4/g� W <br />()%':5( <br />42-01 12 5 I%�� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 � 1 <br />r <br />