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t <br />r <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-REFUNDABLE PERMIT 1 CALL 209 953-7697 FOR INSPECTIONS JEXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS l.i JC1 poi I P CITY/ZIP V / <br />CROSSSTREET I j� L.t/ APN ofaG�a7 PARCEL SIZE �'[X <br />OWNER NAME Z ,\�! i,, df } PHO <br />lNE 1-W ;'/' 9— !91 <br />OWNER ADDRESS JCA., 10c) r' CITY/STATE/ZIP <br />CONTRACTOR. pe ll—r S 1611tAep :0 /1 C ��. PHONE <br />CONTRACTOR ADDRESS i�I L CITY/STATE/ZIP CZ�S <br />LICENSE ,_ C-42 ❑ C-36 OTHER NUMBER D EXPIRATION DATE.��� <br />WATER TABLE DEPTH: _ CIO ft GEOGRAPHICAL INFORMATION: Coordinates X Y_ <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION j ­ REPAIR/ADDITION ENGINEER DESIGNED <br />REPLACEMENT TA I1 k -r r Ie, iCll OUT -OF -SERVICE SEPTIC SYSTEM Df Ut51 KUG I IUN J -1 r 1 r <br />INSTALLATION WILL SERVE: RESIDENCE [ICOMMERCIAL 1�O E) a1er1Cr❑ OTHER <br />P <br />NUMBER OF LIVING UNITS' NUMBER OF BEDROOMS: Q NUMBER OF EMPLOYEES: <br />TERNATIVE <br />ASEPTIC TANK <br />TYPE/MFG L-, <br />CAPACITY (/ gal # OF COMPARTMENTS 2— <br />❑ GREASE TRAP <br />TYPE/MFG <br />gal # OF COMPARTMENTS <br />Permit/ <br />Service Request # <br />rCAPACITY <br />DISTANCE TO NEAREST: WELL J b ,-,z ft <br />FOUNDATION Lb �-� ft PROPERTY LINE <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />i LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES_ LENGTH OF LINES ft <br />leo o SL16� <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION/b )� ft PROPERTY LINE f ft <br />❑ FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />^ <br />FOUNDATION ft PROPERTY LINE PVa Itrikhft <br />ElMOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />❑ SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH FPO 4 ft <br />ft <br />FOUNDATION ft PROPERTY &92 ft <br />DISTANCE TO NEAREST WELL <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH �qQU/ ft <br />DISTANCE TO NEAREST WELL J <br />FOUNDATION ft PROPERTY LC�{BM T41 ft <br />SEEPAGE PITS <br />NUMBER --? WIDTH 3 <br />ft DEPTH TME ft <br />DISTANCE TO NEAREST WELL_,e ft <br />FOUNDATION /� �� ft PROPERTY LINE f1 <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 <br />OF SAN JOAQUIN COUNTY. <br />MINI <br />48 HOUPLADVAIXE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED <br />TITLE DATE <br />DEPARTMENT USE ONLY 1' --, " II.� <br />Application Accepted By 1— L� Date �� 2 Area Employee ID# (c oK <br />Final Inspection BylEa� <br />Date 7 [ISPECIAL PERMIT -Approved by <br />Character of Soil to Depth of Ft: Pit/Sump Soil Character: <br />lI.-I <br />COMMENTS fesrS GISJ S stow n GIS C �7a 1 iLde'r-100, L.` Ise ��'�i 1 oc::5 G he'ogdonPG <br />A) e IA/ 14 r Y) CS (ln o rt TJ <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />a► o <br />I s <br />20 f; <br />t 3 o o <br />leo o SL16� <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />Lp <br />:.I <br />t� <br />O <br />0 <br />m <br />