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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 n GALL 2U9 9�53--7697 FOR INSPECTIONS CXPIRES l YEAR FROM DATE ISSUEI <br />JOB ADDRESS 2S- A -g O /V • 6 (LA H Awl )` 1> CITY/Zip AC AYA 1D a 977-2-O <br />CROSS STREET C O L L I CnF APN 0d� - `S -40 PARCEL SIZE 3 • IV If A <br />OWNERNAME JV ST/YV r i�QY.t'.� PHONE (S- 30) 5-1'1 -31 S,f <br />OWNER ADDRESS 5�AvWUE CITY/STATE/ZIP <br />CONTRACTOR LIVE U�yAI"-y1 K�0101,114-G£D�NvitZorVw�EN i AL- PHONE 3to9 -D3-1 A <br />CONTRACTOR ADDRESS w'0101,114-CITY/STATE21P LVT> k GA -` 294 0 <br />-7 <br />LICENSE ._ C-42 !- C-36 OTHER C- L c" NUMBER i- 1 S" EXPIRATION DATE -T _3 0 - -2-2 <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE I COMMERCIAL OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPEIMFG CAPACITY gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL It FOUNDATION It PROPERTY LINE It <br />❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES ft <br />Code <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE It <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />It DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />ft PROPERTY LINE R <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />ft PROPERTY LINE It <br />❑ SUMPS <br />WIDTH <br />It LENGTH <br />ft DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />ft PROPERTY LINE It <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />It DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />ft PROPERTY LINE It <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 4 <br />R ADV E NOTICE <br />RE <br />IRED FOR INSPECTIONSD- <br />PLEASE 9 CALL 2 -7 7 <br />SIGNED <br />TITLE r J040J' <br />m �� ' DATE 2 - <br />PAYMENT <br />'DECEIVED <br />-� DEPARTMENT USE ONLY <br />�J / <br />Application Accepted By �—r_ <br />Date aR Area 1 `/ G Employee ID# 1 <br />Final Inspection By Data -Z, L L' Z Z -,! SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />PE <br />SC Received Check / <br />Amount Date <br />Permit/ Invoice # Permit ID# <br />Code <br />INFO Cas <br />Remitted <br />Service Request # <br />aaa <br />sa3 <br />Ise .z <br />00 gyIg I 5Z <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />. 0 2 2022 <br />JOAQUIN COUNTY <br />NVIRONMENTAL <br />LTH DEPARTMENT <br />