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0 <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVUN-KtFUNUAI3LE PERMIT GALL 2019 953-7697 FOR INSPECTIONS /EXXPIIRRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS �/ ?/�-zSI T" ' r /-�'q, �C' CITY/7ZI'P �G�L/ J/�Q < �% <br />CROSS STREETS (,"�;-1►y/ 7 12— A APN /Jy < PARCEL SIZE <br />b. <br />OWNERNAME�tiPHONE <br />OWNER ADDRESS CITY/STATE/ZIP <br />LAA�Lr9" 7 j <br />CONTRACTOR Ft► `� PHO E <br />CONTRACTOR ADDRESS 61 v I /rC�iv rCKJ CITY/STATE/ZIP _ //-'y� [iy� (� J a <br />LICENSE ❑❑C-42 110C-36 OTHER NUMBER C,/`) -7 EXPIRATION DATE ��� 2L027 <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION 401 REPAIRIADDITION ❑ 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 />❑ <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 <br />CAPACITY <br />FOUNDATION <br />❑ PKG TX PLANT <br />❑ <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />ft <br />❑ <br />LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE To NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />19 <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />z <br />ft DEPTH �J�. <br />ft <br />DISTANCE TO NEAREST <br />WELL / ft <br />FOUNDATION � ft PROPERTY LINE S^ / <br />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 />Application Accepted By Date YJ- Area Employee Ili <br />Final Inspection By Date J �- ❑ SPE IAL 1'67----7 <br />ERMIT - Approved by <br />Character of Soil to Depth f 3 Ft: Pit/Sump Soil Character: <br />COMMENTS Dr;5W7, Fh E�jyfI i Tf-5f-ff, UXANE1'r"Of/W <br />PE SC Receivedhec Amount Date Permit/ <br />Code INFO By ash Remitted I Service Request # <br />42-01 <br />4/14/16 <br />Invoice # I Permit ID# <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />