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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 <br />IVUN-tsthUNUAttLh P -L -.HMI l (-ALL (ZUbf)&0J-10V1 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUI <br />JOB ADDRESS 15-7 tq(p ^i . -j>eVIe I E.S /`7C> • t— CR--Y1%LIP L OD I Q <br />CROSS STREET 5e�� /V T APN z'.7 - / D - 3 PARCEL SIZE 3OC • / Ar - <br />OWNER NAME-JA-C)C-1,1 j ^ J ff4AL' j PHONE 511-1) 2.5 - -7 D <br />OWNER ADDRESS SPINE CITY/STATE/ZIP <br />CONTRACTOR LiV C 0,6s -K. GL`Ot/�y«0-IJ*1EVy i t'tL PHONE 3/o9-0-31 $— <br />CONTRACTOR ADDRESS q-0, W - 0 AV-- -- ST - CRY/STATEIZIP L-- 0-D I cA 9 2-4 L� <br />LICENSE 1310C-42 11oC36 OTHER C - E76 -NUMBER y' �- I EXPIRATION DATE T ` 30 - Z Z -- <br />D <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />}}i PERC TEST #___L__ <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />C NEW INSTALLATION ❑ <br />REPAIRIADDIT10N <br />C ENGINEER DESIGNED/ALTERNATIVE <br />ft PROPERTY LINE ft <br />'',.7 REPLACEMENT [.I <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />❑ DESTRUCTION <br />INSTALLATION WILL <br />SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />WELL <br />NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASETRAP <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 />S¢E TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />0 LEACHING CHAMBERS <br />#OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft 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 <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCAT10N 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 />SIGNED <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Depth of 3 <br />COMMENTS <br />TITLE_ Ag -OJ J - M G(?- - DATE S- 4+ ` Z I <br />Lex, iwuunax weu �wY <br />AEMWU <br />jz- <br />FLWY /1 <br />Date S��/ �� Area I � 61 <br />Date ❑ SPECIAL PERMIT <br />Pit/Sump Soil Character: <br />I <br />Employee ID# k1 <br />Approved by <br />PE SC Received Check# Amount Permit/ <br />Code INFO B Date Remitted Service Request # Invoice# PermitlD# <br />';)aas� ►�1 2a S <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />