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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 />IYUN-HEhUNDABILE PERMIT r� L;ALL (ZU9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI <br />- <br />JOB ADDRESS -1q 11 W ` C �9 Ey " r7 CITY(-2I�P� �� /R�" <br />CROSS STREET C1�12,S rAA�% APN `�- 'y- TO PARCELSIZE Q''S-k- <br />jos <br />i <br />OWNER NAME ✓ O S.yC Y"v "`-n Qcx PHONE �e, "�b�•r <br />OWNER ADDRESS <br />ell) <br />f,,F f �O �+0L�C"` ft ' G� N C �� RA • <br />/ S'rE.• 5 CITY/STATEMP M aDes-m� C� 17s-35-1 <br />CONTRACTOR LAVE- OFhL 6MEAJV1F-Z" ►1eXrwt_ PHONE -711!99 "031' <br />CONTRACTOR ADDRESS 'fC'l w . 0 AV- 31% CITY/STATE/ZIP L II C -1 p <br />x24'0 <br />LICENSE I..'. C-42 0GG36 OTHER C- 'E& NUMBER 7-1 5 EXPIRATION DATE <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />PERC TEST # <br />I BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEW INSTALLATION <br />REPAIR/ADDITION <br />ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL SERVE: __' RESIDENCE <br />COMMERCIAL <br />OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES <br />pN° <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ff PROPERTY LINED <br />L­ <br />EllE•ll��Y, <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH <br />V�l <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />�� ff <br />❑ MOUNDED <br />WIDTH <br />DISTANCE TO NEAREST <br />ft LENGTH <br />WELL <br />It DEPTH <br />ft PROPERTY <br />IV <br />�02? <br />ft FOUNDATION <br />ft <br />LINE <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH <br />vryry /� ,,� <br />Oi IIR <br />'V <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />��p"���i• <br />-"•SRO <br />��NT <br />❑ DISPOSAL PONDS WIDTH <br />If LENGTH <br />ft DEPTH <br />pEP <br />MEN7 <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />ft <br />DISTANCE To NEAREST <br />WELL <br />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 <br />AND RULES AND <br />REGULATIONS OF SAN JOAQUIN <br />COUNTY. <br />MINIMUM 49 gOUR ADVANCE NOTICE RE IRED FOR INSPECTIONS - PLEA E CAI 1- (209)-7 1 <br />SIGNED {/ '� TITLE P)2-0-1 • VKC:"-( 4'• DATE t' (7 --ZZ <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Depth of 3 <br />COMMENTS <br />TMENT U <br />Date SE NArea Employee ID# <br />_k <br />Date 1.4 /o /ZZ ❑ SPECIAL PERMIT -Approved by <br />PiVSump Soil Character: <br />PE SC Received heck Amount <br />Code INFO B ash Remitted <br />Date Permit/ Invoice # Permit ID# <br />Service Re uest # <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14118 <br />