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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 CALL 209 953-7697 FOR INSPECTIONS tXPIRES "I YEAR FROM DATE 1551JIEI <br />JOB ADDRESS 4 'edCITY/ZIP�J /� Ir1 eco, S <br />CROSS STREET N Lt, y i"? j j I APN d'2 R O O 7 �'] PARCEL SIZE 0757- <br />OWNER <br />7� <br />OWNER NAME rnan t/ I �s'" Ila ltlA o C PHONE <br />OWNER ADDRESS 3y331 n1s�4j jam% CITYISTATE/ZIP i1\ay)+erC, ('C, _ <br />CONTRACTOR�1 �liJ�f l l/`IL !_Jf Ar✓I f I /L✓��1 Y'� PHONE <br />CONTRACTOR ADDRESS . C. POr+A(. aVe, CITY/STATE/ZIP <br />LICENSE ❑LIC -42 11/C-36 OTHER NUMBER 1033-A�- 2 <br />EXPIRATION DATE �� l ^ Z <br />WATER TABLE DEPTH: D 1 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: CI NEW INSTALLATION e REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />1-1 REPLACEMENT 1.] OUT -OF -SERVICE SEPTIC SYSTEM I.I DESTRUCTION <br />11 <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL PC f ❑p OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: `I P4', ' i �I ' e% NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />CAPACITY <br />CAPACITY <br />ft FOUNDATION <br />❑ PKG TX PLANT <br />7 <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />1=-74- <br />❑ LEACHING CHAMBERS / # OF LINES 1 LENGTH OF LINES -ft <br />DEPARTMENT USE ONLY <br />DISTANCE TO NEAREST <br />/ <br />WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH ft DEPTH _ <br />ft <br />�` <br />DISTANCE TO NEAREST <br />_ <br />C <br />WELL U ft FOUNDATION �� Fl ft PROPERTY LINE 5U <br />ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH ft DEPTH <br />ft <br />Character: <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH ft DEPTH <br />ft <br />c i <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />IIHHEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICA AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAW D Rk1LES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />AfiNM <br />48 HOUR ADVANCE <br />OT E REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNta-- <br />TITLE DATE <br />V PE <br />Code <br />_ <br />DEPARTMENT USE ONLY <br />LL •"y�zP11W�(q �r`r�/ <br />%►?fy1Tf[G Employe3'KJ{�% (7 <br />Application Accepted By <br />� <br />Date <br />d as <br />Area <br />Final Inspection By <br />�` <br />Date <br />SPECIAL PERMIT -Approved by <br />Character of Soil to Depth <br />of Ft: <br />Pit/Sump Soil <br />Character: <br />COMMENTS Ut1K 11 <br />'v41191K <br />LXI' �Ih <br />Y)e-5-� <br />fo St <br />iv evt�r ; �, 30 <br />re <br />f �: <br />c i <br />r r %ss f he l �r r <br />V PE <br />Code <br />SC Received <br />INFO Bv <br />Chec <br />ash <br />Amount Date Permit/ <br />Remitted 4 Service R quest # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />T <br />