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n <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT Q (;ALL (ZU51) 953-7697 FOR INSPECTIONS/ EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS , " DL) C C_ I �Z_L_ _---_---- CITY/zIP I = "LS Z 44 C - <br />CROSS STREET r! 1 11�� `` 4i APN(%I ` 10 lI t2 PARCEL SIZE <br />OWNER NAME E1✓LZrR?V / <br />1 ���1"l�l[`y�• c�dsmN PHONE <br />OWNER ADDRESS <br />f, <br />OWNER / 6�(v14 CITY/STATE/ZIP <br />CONTRACTOR Cc�/t/STi2i rC 1��/ SL i�G� /✓�. PHONE <br />CONTRACTOR ADDRESS EL % /ZrSE`:V LFe[(C j>Z ZL' • /C ZLZI CITY/STATE/ZIP <br />LICENSE I_Yi'C:-42 LJ C-36 OTHER NUMBER Z �� EXPIRATION DATE Ov. d Z <br />I ---I. I . \ -�� <br />WATER TABLE DEPTH: '�U �_�/ V _ ft GEOGRAPHICAL INFORMATION: Coordinates X - Y <br />PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION R PAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />RFPI ar.FMFNT 011T-0;=-SFQVIrF GFPTIr-:VCi'FRA nr'TPI IrTl(1N <br />INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: - ( NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPF/MFC; �3C �� Z�Lc CAPACITY /5oo flat 9nF(nMPARTMFNTS 2 <br />❑ GREASE TRAP <br />TYPE/MFG <br />Received <br />By <br />CAPACITY <br />gal # OF COMPARTMENTS <br />Date <br />DISTANCE TO NEAREST: <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE _— TYPE OF PUMP <br />C3PKG TX PLANT ElSAND <br />OIL SEPARATOR (ENCLOSED SYSTEM) <br />VIZ <br />Z7ZAq-v1x <br />2 <br />U LEACH LINES <br />LEACHING CHAMBERS <br />_ # OF LINES _ <br />LENGTH OF LINES <br />DISTANCE TO NEAREST <br />WELL %00 f ft <br />FOUNDATION kS� ft PROPERTY LINE 2 C ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL 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 ft <br />FOUNDATIONf <br />t PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL 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 ft <br />FOUNDATION <br />ft PROPERTY LINE It <br />SEEPAGE PITS <br />NUMBER / <br />WIDTH FIs " <br />ft DEPTH 2S ft <br />DISTANCE TO NEAREST <br />WELL �S b Y It <br />FOUNDATION / <br />ft PROPERTY LINE Za ft <br />1 HEREBY CERTIFY THAT <br />i HAVE PREPARED THIS APPLICATION <br />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 />Application Accepted By <br />Final Inspection By — <` <br />Character of Soil toDepthof 3 Ft: <br />COMMENTS //r�. <br />//y/ CArea <br />g <br />?Z,.,:S—r'`—i 11w�; ! SPE <br />Pit/Sump Soil Character: <br />DATE O <br />Employee ID#� <br />PERMIT - Approved by <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />PermiU <br />Service Re uest # <br />Invoice # <br />Permit ID# <br />l <br />2 <br />42-01I Aj%�� <br />v� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />rr <br />