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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-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS /� /1 EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS Ila W, 2ft�� �/✓ CITY/ZIP L219 -C4 <br />CROSS STREET )t. fd ,q APN r) S PARCEL SIZE -1,39 <br />OWNER NAME �I[�I�/� L' l (Z,/ ///��// PHONNEn�'�iS'/-36��s�7��f <br />OWNER ADDRESS 4�T/AA n� �Q 2A//l L jive- 1'-v CITY/STATE/ZIP (,L</ TL/J,,✓/ �% <br />CONTRACTOR i1 SgAn ) � � AJC+YLi�� Sf?F �IC, PHONE g0 Cl Sac/-- (/ <br />1 r <br />CONTRACTOR ADDRESS I(T V I A y G CITY/STATE/ZIP /l 1 o k l Q <br />LICENSE ❑ L C-42 V C-36 OTHER NUMBER I'V O EXPIRATION DATE / I A30 Jas <br />WATER TABLE DEPTH: ft ft GEOGRAPHICAL INFORMATION: <br />❑ PERC TEST # BUILDING PERMIT## <br />TYPE OF WORK: NEW INSTALLATION C REPAIR/ADC <br />Coordinates X <br />LAND USE APPLICATION #_ <br />)N i ENGINEER DE <br />REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION <br />91 <br />GNED/ALTERNATIVE <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br />❑ <br />❑ <br />❑ <br />SEPTIC TANK <br />GREASE TRAP <br />LIFT STATION <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />ft <br />CAPACITY gal # OF COMPARTMENTS <br />CAPACITY gal # OF COMPARTMENTS <br />FOUNDATION ft PROPERTY LINE ft <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />r <br />LEACH LINES <br />LEACHING CHAMBERS <br />Permit ID# <br /># OF LINES <br />LENGTH OF LINES 0`6�-eff ft <br />VI P <br />+300 <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION -9' 0 <br />ft PROPERTY LINE 0 ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />It <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />It <br />FOUNDATION <br />ft PROPERTY LINE ft <br />1 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 />IvIIIYIIV/V 40 n V HL.FVH/vl+C IvV IIVC rCC VIr%V-" rVrt ►Ivor -L--' 'I IWIV O lzu: <br />SIGNED TITLE C9 I/'�ry �, ` DATE <br />DEPARTMENT USE ONLY M Nr <br />Application Accepted By —� LG Date 1 ,;? Area S Employee ID# <br />Final Inspection By Date �� ZZ ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS E xlsY+"'ti I� ylFs fo reY��� ln: (a I ,VSiP,Yrr <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />RemittedService <br />Permit/ <br />quest # <br />Invoice # <br />Permit ID# <br />VI P <br />+300 <br />*Dat <br />D �' <br />42-01 ' ' -� 7(2Y A f / ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 lvJ \ ✓�X <br />