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V-1 <br />i 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 PERMIT <br />GALL��(ZUy) 903-/6y/ FOR INSPECTIONS <br />tXPIRES 'I YEAR FROM UATE ISSUE <br />JOB ADDRESS D'(O CA C <br />�` -� K r CITY/ZIP a-"� <br />Q11 a c-- i <br />53� <br />Ere <br />» i1 ak APN 2' t O %� /� <br />� L I 0 <br />PARCEL SIZE <br />CSD <br />CROSS STREET <br />--C T� <br />TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />122 <br />-,A <br />OWNER NAME - ,A <br />f� C0 <br />PHONE <br />Ul LEACH LINES <br />OWNER ADDRESS �� ` <br />!S)✓y <br />/ <br />N (S 1��- I` �`�✓ CITY/STATE/ZIP <br />SG4 ,Jt) <br />C� <br />CONTRACTORf J: I.p�. <br />PHONE <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED <br />CONTRACTOR ADDRESS 16 WJL7k <br />(o_Gi1 CITY/STATE/ZIP <br />W10 -1A -ft --A j 6Vf- <br />SUMPS K 3 <br />LICENSE ❑CC -42 ❑CIC -56 OTHER 11J NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />_' PERC TEST # <br />BUILDING PERMIT # - 7 LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEW INSTALLATION [! REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />Permit/ <br />Service Request # <br />REPLACEMENT G 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 />Q' SEPTIC TANK <br />TYPE/MFG �a-L CAPACITY ((B n 21 gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />122 <br />DISTANCE TO NEAREST: WELL (64� ft FOUNDATION I �� ft PROPERTY LINE LiQ, ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />Ul LEACH LINES <br />LEACHING CHAMBERS # OF LINES 3 LENGTH OF LINES �TQ t ft <br />DISTANCE TO NEAREST WELL 166,1- ft FOUNDATION _ft PROPERTY LINE 145, ft <br />❑ FILTER BED <br />WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />SUMPS K 3 <br />1 <br />WIDTH �� ft LENGTH —91 1 ft DEPTH 101 ft <br />DISTANCE TO NEAREST WELL 2Q) I- ft FOUNDATION (Q61 ft PROPERTY LINE �Q I ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft 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 />MINIMUM 48 HOUR Al2VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED <br />TITLE C—t7l DATE <br />g ) DEPARTMENT VSE ONLY lj <br />Application Accepted Bye,� Date Area ICr Employee ID# <br />Final Inspection By v. /-1, Date (% 2* 1 2 Z- LJ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS V -P (O �l� r ,l C--c'ak- -;-A-//21 1-e4c%t/Iiektiu d <br />gob s <br />I <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />8 <br />-• 5 <br />122 <br />0 yIF <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />