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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 <br />JOB ADDRESS t7 Civ IL <br />CROSS STREET <br />OWNER <br />CALL (LUY) 9b3-/6YI FOR INSPECTIONS CXNIKtS I T LAK t- <br />30 <br />30 JFGIO KCl") CITY/ZIP <br />APN 8ro 13- 0 �? t:' PARCEL SIZE <br />PHONE <br />OWNER ADDRESS ?j-coOb - b9-7 K e4s5or CITY/STATE/ZIP <br />CONTRACTOR A�le(-, J. -r_ 4�' ^C �� �� �/�' ^ PHONE <br />CONTRACTOR ADDRESS r� / `� � L " CITY/STATE/ZIP ";?,7O '4 <br />LICENSE ❑0C-42 ❑TIC -36 OTHER <br />NUMBER (/ J �,�� EXPIRATION DATE �/Z Tu 2 d2 2— <br />WATER <br />WATER TABLE DEPTH: ! 11 �' j'esS ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: 0 NEW INSTALLATION 1' ❑ REPAIR/ADDITION 0 ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT t-liy < � �i 2 I� ❑ OUT -OF -SERVICE SEPTIC SYSTEM YI DESTRUCTION 16ld- <br />1 <br />INSTALLATION WILL SERVE: /ff RESIDENCE ❑ COMMERCIAL Unq ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 2, �CD� �I (� NUMBER OF EMPLOYEES: <br />4' SEPTIC TANK TYPE/MFG �/ G `o" cIe- c- CAPACITY gal #OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL T111bl (L ft FOUNDATION �® f ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES ❑ LEACHING CHAMBERS # OF LINES <br />LENGTH OF LINES <br />ft <br />Amount <br />Remitted <br />D e <br />Permit/ <br />Service Request # <br />ft <br />Permit ID# <br />DISTANCE TO NEAREST WELL ft <br />ft PROPERTY LINE <br />�) <br />UFOUNDATION l <br />FILTER BED WIDTH �ID ft LENGTH % 09"`! J ft <br />DEPTH t v7 �1g0� ft <br />DISTANCE TO NEAREST WELL WU4 ft FOUNDATION <br />ft PROPERTY LINE s <br />ft <br />❑ <br />MOUNDED WIDTH ft LENGTH ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />SUMPS WIDTH ft LENGTH ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <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 />ewunewO 1ne wd4-1n1 m A nvA ftit%= lkinrrre Dcfm iiDCn rno IAI4zDFCT1n A/C - PI Fd.i'F rzi 1 (iO9) 9.53-70397 <br />TITLE l di✓ ����� <br />EPARTMENTU EONLY 0 5 <br />Application Accepted L L DDate Area /9 <br />`7 Employee ID#� <br />Final Inspection ByB Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: it/S mp Soil Character: <br />COMMENTS Q ,IOGtIr U)ILIO)n1 ler✓ <br />6i Y11<7 091r e G �rs1Pvi7e <br />-6f foC k under 0;,ne Ajn rle"y- 7hanw" <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Ch <br />Cash <br />Amount <br />Remitted <br />D e <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />L l 0 <br />) s" <br />Sze <br />3aO <br />1 2 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />VA- <br />-3 M <br />0 <br />b <br />N <br />