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I I` -I -I I <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 ,{ , LOnl CALL (ZUY) 953-7697 FOR INSPECTIONS tXPIRESS I TEAR FROM UATE ISSUEI <br />JOB ADDRESS / 7.2 3.7 4Q ST lsgx: A ✓E CITYIZIP /D 0A,'f!,7 7;LO <br />CROSS STREET Dh/A 4 14" 4Da491-9149-14 APN , PARCEL SIZE Q �• 7 �-/ <br />OWNER NAME A1A4 eQ !STA PHONE a2O � T 8'� <br />OWNER ADDRESS <br />�%J2c7 at •; 9 �• LoG(�SE -A VF • CITYISTATE/ZIP R/P0A1 G� Q s2" <br />(iG <br />CONTRACTOR 546 VIA! r/ 1- PHONE aD� =4ex- -1GS� Q.�y <br />CONTRACTOR ADDRESS -F-- a • Be)( 52 L CITY/STATEIZIP � cA�4Ik, CAT � i <br />LICENSE ❑LIC -42 ❑ ❑C-36 OTHER /`(� NUMBER �J' EXPIRATION DATE <br />WAY R TABLE DEPTH: ti 4-0 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # t BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: G NEW INSTALLATION ❑ REPAIR/ADDITION f I ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT IJ OUT -0F -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />ft <br />CAPACITY <br />CAPACITY <br />FOUNDATION <br />❑ PKG TX PLANT <br />❑ <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 /># OF LINES <br />/J <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft 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 LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft 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 <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE 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 <br />REGULATIONS OF SAN JOAQUIN <br />COUNTY. <br />SIGNED <br />VIA 11yor-C1- I IWIVO - rLCP10C 1.rI`iLL (4V.7/ V%lo-/ V/7/ <br />TITLE C/ V/L 8A14 /1-V/EE/2 DATE <br />EPARTMENT USE ONLY <br />Application­7Application Accepted By Date i f Area Employee ID# <br />Final Inspection By Date 2 , ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth o Ft t_ Pit/Sump Soil Character: <br />COMMENTS ��'7�. �,ln�/�, IZ��^'►i�/I ^1 1 — l�:%/Z,� �/ ems. <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Check#/ Amount <br />ash Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />/J <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />T <br />