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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-KEFUNDABLE FERRMIT <br />CALL (ZU9) 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS a <br />In 9-3 ����I <br />-a--4 a CITY/ZIP <br />❑ LEACHING CHAMBERS <br /># <br />CROSS STREET I <br />XI.�1 <br />APN 1)}} AC �3 <br />PARCEL SIZE <br />%' b <br />OWNER NAME <br />I�G5�1er S�lr��y <br />%�Z <br />PHONE <br />ft LENGTH <br />OWNER ADDRESS <br />S7 �`i Pe 6+' Ave <br />CITY/STATE/ZIP PI161 <br />/,I e(41 <br />5 7 <br />CONTRACTOR__oall <br />15 yy��/) <br />( ?-�C. PHONE `(j e <br />_1Dp&S__ <br />ft LENGTH <br />CONTRACTOR ADDRESS <br />P6C�)r USO <br />CITYISTATE/ZIP //► <br />► —44—e- e4 �Cr/' <br />L <br />LICENSE ❑ ❑C-42 <br />❑ OC -36 OTHER <br />NUMBER (0 EXPIRATION DATE <br />WIDTH <br />ft LENGTH <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # Q,q) 19 LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT Imo" ("� /�/7V6� OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />10- <br />❑ <br />❑ <br />SEPTICTANK <br />GREASE TRAP <br />LIFT STATION <br />TYPE/MFG f <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL ft <br />SIZE TYPE OF PUMP <br />CAPACITY 0gal #OFCOMPARTMENTS <br />CAPACITY gal # OF COMPARTMENTS <br />FOUNDATION ft PROPERTY LINE ft <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />S <br />LEACH LINES <br />E <br />❑ LEACHING CHAMBERS <br /># <br /># OF LINES LENGTH OF LINES O V ft <br />'�ST// ` <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDAI`ION ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE To NEAREST <br />WELL ft <br />FOUNDATION 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 />SIGNED <br />VR I/YJrCIr I IV/YJ - rLCHJC I+MLL IAV. <br />TITLEie-L0"-Oi DATE <br />l DEPARTMENT USE ONLY <br />Application Accepted By 7n Date d'I Area 3 9 Employee ID# <br />Final Inspection By a _ Date \' Q 4, (Z,'O-LA, ElSPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS tJeW SFIZ 6,-)nnec4eri eels INc sMeM, FA)Sh")1� sy5fF;vl t)nder ek 006CIOG <br />UP.rIFI/ P fa SPP!iI 5l57BN► hb&.ee . PeVn^J 1stUerj'DPr r"-'c'raw <br />PE <br />Code <br />SC <br />INFO <br />Received <br />y <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit]Invoice <br />Service Request # <br /># <br />Permit ID# <br />j2 ZZ 21 <br />S+Q <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />