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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 />NUN-HEFUNDABLE F'ERMIi L ALL (ZVY) bF0J--/0J/ 1 -UH I1VS4'6G11U1V5 CXPIHES 1 YEAH ]-HUM UAI E IS5UI <br />JOBADDRESS 2-72.8-o N • &RLAHAw, 0'>, CITY/ZIP A�CYkM9D 9TZ2-0 <br />CROSS STREET C O L L 1 r--?—APN 00-1 � Z� " TO PARCEL SIZE 3 • m if GAt <br />OWNER NAME JV5-r)" PHONE <br />OWNER ADDRESS SRw1.� CITY/STATE21P <br />CONTRACTOR L•lJC UAy—K� G-EONy12o�e�/-mE,n.J Ac L PHONE 3 (0 5 - O3�I S <br />CONTRACTOR ADDRESS �" 1 w ' A�^ J - CRY/STATE/ZIP LO'T> k C A 9 � Z-14 0 <br />LICENSE lJ i IC -42 ❑ uC-36 OTHER C �- � NUMBER 7-1 S' EXPIRATION DATE 14 -3 0 -'2--,L <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST #____L—] BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: C NEW INSTALLATION ._. REPAIR/ADDITION I:1 ENGINEER DESIGNED/ALTERNATIVE <br />:... REPLACEMENT ... 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 />❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />C:i LEACHING CHAMBERS <br />Checkg/ <br /># OF LINES <br />Permit/ Invoice # Permit ID# <br />LENGTH OF LINES ft <br />INFO <br />DISTANCE TO NEAREST <br />WELL <br />Service Re uest# <br />ft FOUNDATION <br />s1;?3 <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />It <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />It <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />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 4AjtQjLR ADV,AKE NOTICE REQUIRED FOR INSPECTIONS <br />jlONn (P� PLEASE CALL DA 09 ^ 1692 Z eENi <br />SIGNED TITLE 1� <br />ECEIVED <br />�� DEPARTMENT U E ONLY _ <br />Application Accepted By � �-- L� �_ Date R � Area Employee ID# <br />Final Inspection By Date ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />PE <br />SC Received <br />Checkg/ <br />Amount Date <br />Permit/ Invoice # Permit ID# <br />Code <br />INFO <br />Cas <br />Remitted <br />Service Re uest# <br />La2 <br />s1;?3 <br />Psi <br />00 yB <br />.1VILL—L <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />2 2022 <br />OAQUIN COUNTY <br />VIRONMENTAL <br />TH DEPARTMENT <br />