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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-KEFUNDABJLE� UL <br />-/� GALL <br />JOB ADDRESS I CQ ®' ( Y- Q C LULC(/ <br />FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE <br />CITY/ZIP <br />CROSS STREET /V`t+4- <br />^yQI-T►�ewa&n�lS{. 1 APN � PARCEL SIZE <br />OWNER NAME GCSfS <br />PHONE <br />OWNER ADDRESS �I :O /�(� G1'X� � 1 _-CITY/STATE/ZIP LC�j�/,) /�� s <br />CONTRACTOR �J�II X11 �7l/�/'/n' 1'C �J PHONE �d %'�,� JJJY• �—%-150 <br />CONTRACTOR ADDRESS % 7 4 TR(►` C CITY/STATE/ZIP ��`� �f� <br />LICENSE 11)6-42 ❑oC-36 OTHER NUMBER O J EXPIRATION DATE / —3 I <br />WATER TABLE DEPTH: lc) ! 10-0 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT# 310139S- LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION - REPAIR/ADDITION 11 ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT 1-1 OUT -OF -SERVICE SEPTIC SYSTEM I I DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL 2 ❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: r J NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG oocr CAPACITY /t�20 gal # OF COMPARTMENTS G;2 <br />❑ GREASE TRAP TYPE/MFG ^,_ CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL /w ` ft FOUNDATION ` ft PROPERTY LINE 3C t ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES Ci LEACHING CHAMBERS # OF LINES <br />DISTANCE TO NEAREST WELL C C ft FOUNDATION—i <br />❑ FILTER BED WIDTH ft LENGTH <br />DISTANCE TO NEAREST <br />❑ MOUNDED WIDTH <br />DISTANCE TO NEAREST <br />Ll!] <br />0 <br />WELL ft FOUNDATION <br />ft LENGTH <br />WELL ft FOUNDATION <br />t <br />ft <br />ft <br />LENGTH OF LINES 55 / ft <br />ft PROPERTY LINE ft <br />DEPTH ft <br />ft PROPERTY LINE ft <br />DEPTH ft <br />ft PROPERTY LINE ft <br />SUMPS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO /EEAREST WELL ft UNDAT]ON ft PROPERTY LINE ft <br />SEEPAGE PITS NUMBER J WIDTTH� 13 p ft DEPTH ft <br />DISTANCE TO14tAREST WELL %7 C� r ft FOUNDATION G d ft PROPERTY LINE �d ft <br />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 />Final Inspection By Date 3�- 2�-7 C SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS IjeIJ F ::�Ger _ <br />PE <br />Code <br />SC <br />INFO <br />Received Ch <br />By Cash <br />Amount Dat Permit/ Invoice # <br />Remitted Service Re e t # <br />Permit ID# <br />�911 <br />jj7 <br />4s<q 090 H <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />