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l IL <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-KEFUNDABLLLE l'ERMII <br />JOB ADDRESS 19950 <br />CROSS STREET to <br />OWNER <br />CALL (, <br />AD <br />y0:f-/05/ FOR INSPECTIONS J LXPIRES l YEAR FROM UATE ISSUE <br />T /ZIP /�S C1� C V 7 Z <br />APN f- I U I PARCELSIZE L ✓� <br />to__' PHONE <br />OWNER ADDRESS 9 - _ CITY/STATE/ZIP <br />CONTRACTOR y / i ItL-e-ts C C,(z4 -y-r— C_'e ( • PHONE ✓����^` �LO <br />CONTRACTOR ADDRESS Ion i�ax C/ o CITYISTATE/ZIP ►/(� ` /�-t/�I L/�' / q <br />� jl <br />LICENSE ❑❑C-42 ❑0C-36 OTHER 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: 11 NEW INSTALLATION CV1 REPAIR/ADDITION ❑ ENGINEER DESIGNED <br />❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM Pl DESTRUCTION <br />INSTALLATION WILL SERVE: 4,4 ESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br />TERNATIVE <br />❑ SEPTIC TANK <br />TYPE/MFG <br />Received <br />By <br />CAPACITY gal # OF COMPARTMENTS <br />Amount <br />Remitte <br />❑ GREASE TRAP <br />TYPE/MFG <br />Permit ID# <br />CAPACITY gal # OF COMPARTMENTS <br />115- <br />DISTANCE TO NEAREST: <br />WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />O/ LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES LfQI <br />ft <br />DISTANCE TO NEAREST <br />WELL I ZB d-' ft <br />FOUNDATION -701 ft PROPERTY LINE .�OI <br />ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />SEEPAGE PITS <br />NUMBER 2 <br />WIDTH dgklw� <br />34.4 ft DEPTH o1 -'s I <br />ft <br />DISTANCE TO NEAREST <br />WELL��� d" ft <br />FOUNDATION C 4- ft PROPERTY LINE (7/ <br />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 REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINIMUM 48 HOUR ADV NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED <br />TITLE DATE <br />Application Accepted B" `� <br />Final Inspection By L_ <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS <br />i t- <br />DEPARTMENT USE ONLY <br />Datez ?Area 2 ! f Employee ID# <br />Date ❑ SPECIAL PERMIT -Approved by <br />Pit/Sump Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Check <br />as <br />Amount <br />Remitte <br />Date Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />IUR <br />115- <br />-5R®0 84 a <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4114/18 <br />c� <br />Y <br />v <br />d <br />n <br />