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e <br />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 ZU9 9/5�3-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS 72 {y�1�5 (� <br />Act yet, IG S d IC Q <br />�/� <br />CITY/ZIP y ► ► cnd <br />j= C,GIq / Gqj 15-336 <br />.L <br />CROSS STREET 1 1 (J .moi r I <br />`y� <br />i R APN �y <br />I, <br />lJ� V <br />PARCEL SIZE �CJ <br />OWNER NAME�et eiztj L� <br />d0 ^ <br />/`�� td n crLG. <br />FOUNDATION ft PROPERTY LINE ft <br />PHONE <br />OWNER ADDRESS S c_ <br />ft LENGTH <br />CITYISTATE/ZIP <br />�J <br />CONTRACTOR V" I I(L1 rSCi <br />CIG"�_ �G r• <br />PHONE <br />1C_n <br />CONTRACTOR ADDRESS jo6 <br />F- n)c l <br />CITY/STATE/ZIP <br />/ Q <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />LICENSE 11LIC-42 ❑CIC -36 <br />OTHER NUMBER <br />EXPIRATION DATEQa <br />�-- <br />WATER TABLE DEPTH: do, 7 <br />7O ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: 11 NEW INSTALLATION REPAIR/ADDITION ri ENGINEER DESIGNED /ALTERNATIVE <br />Fj REPLACEMENT ❑ OUT -0F -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: �SIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: —3 NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY <br />CAPACITY <br />DISTANCE TO NEAREST: WELL ft FOUNDATION <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />b LEACH LINES <br />❑ LEACHING CHAMBERS <br />f <br /># OF LINES LENGTH OF LINES ft <br />'___Check 9/ <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION l6' ft PROPERTY LINE -Qt 1 ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />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 A VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED <br />TITLE C/DDATE 1,a I OLl <br />/ DEPARTMENT USE ONLY <br />Application Accepted By r� li Date .7/ Area 3 Employee ID# <br />Final Inspection By Date 01_❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: it/S rnp,Soil Character: <br />r <br />COMMENTS 7(_s6 fic,rt%��;q(/• is �g.;1� ����Y�S1, EC4I'1InA ciz'4em_ rr'�s►rl� :�C'j d 1-0 <br />bC t�/ jrr�'e RPe 1Ir r►or 4.0 bp Ili t%(7jILI-{e��1 �#!'Pc� <br />PE <br />Code <br />Sc <br />INFO <br />Received <br />B <br />'___Check 9/ <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />