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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-REFUNDAB <br />,L <br />/E P�E`R'7MIT u L;ALLL r2U& &bJ-/bY1 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE <br />JOB ADDRESS T DQ L SV' r' • $?-+ •99 L' %(40^J7 CC -C p Crry//1ZIP <br />CROSS STREET yC L Ft (-K APN I � / � I 1 •L -S (P PARCEL SIZEe )2I � • <br />OWNER NAME C-K- <br />(��(z" cA94�1 EIZ /�C -� q yPHONE <br />(�S1O) c113 Jq.r&6 ZT <br />OWNER ADDRESS �O lD -1 6OLD Aju6&&-r g -T I ( L- CRY/STATE/ZIP C -r t P 1 I I"K� P � / J 33 <br />CONTRACTOR LIVE OA)= G�E�v11�aN�1r•N•T�L PHONE 3(09-0315 <br />CONTRACTOR ADDRESS 4 0") w . O ' 'r ST. CrTY/STATE/ZIP ( �'� `� S -1 -'j -7D <br />LICENSE --iC-42 01L)G36 OTHER CEv- NUMBER � 15' 1 EXPIRATION DATE - 30 - 2 -7 <br />- <br />D <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 G <br />REPAIR/AODITION <br />D ENGINEER DESIGNED/ALTERNATIVE <br />I..i REPLACEMENT ; <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 />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 <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 />I:.. LEACHING CHAMBERS <br /># OF LINES <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION_ <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />O <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION _ <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />O <br />DISTANCE To NEAREST <br />WELL <br />ft FOUNDATION_ <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION_ <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />a0 <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />DISTANCE To NEAREST <br />WELL <br />ft FOUNDATION <br />n <br />ft <br />ft <br />ft <br />LENGTH OF LINES It <br />ft PROPERTY LINE ppp��� <br />DEPTH II <br />yTft PROPERTY LINE �� <br />DEPTH ft prN <br />ft PROPERTY LINE ft� <br />DEPTH �t •, <br />ft PROPERTY LINE 'l/Y /r ft <br />DEPTH F z7AQl14/ Co <br />ft PROPERTY LINE I TN' Tfd�1tt NIT,q �� <br />DEPTH �pfT ` Tfvl�Nr <br />ft PROPERTY LINE 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 A kjOUR ADWNCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL209 953-7.6917 <br />SIGNED TITLE <br />P%LO.3• /'�'1&A- DATE 1-i`i-zz <br />--_ <br />O <br />O <br />O <br />_ m <br />Oar <br />O <br />� <br />O <br />J O O <br />a0 <br />----------- -------------- ----------- <br />Application Accepted By <br />Final Inspection By_ <br />Character of Soil to Dept <br />COMMENTS <br />of 3 <br />------------- I --------- I --------- --------- I --------- <br />------------------------------------------------------ <br />Area _ <br />❑ SPE <br />Pit/Sump Soil Character: <br />Employee ID#�� <br />PERMIT -Approved by <br />PE SC Received Chec Amount Date Pe'-i'/Invoice # Permit ID# <br />Code INFO B Remitted Service Re uest # <br />i l `2 0 3 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />