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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-KEFUNDABLE VERMIT <br />(:ALL Y YbJ <br />/tiYl FOR INSPECTIONS <br />EXPP/I S 1 YEARFROM DATE ISSUEI <br />JOB ADDRESS <br />C <br />I <</I C74d <br />CITY/ZIPC <br />2/ <br />CROSS STREET <br />" � " <br />TYPE OF WORK: <br />APN O 0 9' 8 O O 6 <br />PARCEL SIIZE o <br />OWNER NAME (_I/DY <br />1C��yPlHON6P <br />ENGINEER DESIGNED / L <br />RNATIVE <br />` y 10 <br />OWNER ADDRESS <br />! �a <br />o 7 <br />"' <br />CITY/STATE/ZIP <br />G C�� /J <br />(J <br />CONTRACTOR <br />/Up/� <br />4 \ <br />� / c— <br />qCl--•! <br />PHONE �/ <br />❑ COMMERCIAL <br />CONTRACTOR ADDRESS <br />( <br />q e- <br />CITY/STATE/ZIP S �'/ (✓ �� <br />LICENSE ❑fEC-42 <br />❑1IC-36 OTHER 14NUMBER�EXPIRATION DATE <br />NUMBER OF BEDROOMS: <br />WATER TABLE DEPTH: <br />SC Receiveeck#/ <br />INFO j BY CR sh <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />99d I <br />C <br />PERC TEST # <br />9 <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />n. NEW INSTALLATION <br />REPAIR/ADDITION <br />ENGINEER DESIGNED / L <br />RNATIVE <br />REPLACEMENT <br />_ <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION 1 CS ('1 " <br />%��' l7`)7 ei <br />INSTALLATION WILL <br />SERVE: C RESIDENCE <br />❑ COMMERCIAL <br />❑ OTHER <br />UMBER OF LIVING UNITS: <br />NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />/ <br />SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />T <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />- LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft 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 FOUNDATION <br />ft PROPERTY LINE i <br />ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH i <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />It <br />❑ <br />SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LANE <br />It <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY INE <br />ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <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 />y� %) <br />DEPARTMENT-USdE ONLY <br />Application Accepted By z__ Date i Area C Employee ID# FR <br />Final Inspection By �, Date "/ lP(Z .Z ❑ SPECIAL IT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS SJI`0ziU-'E S�,IL�/1, �o nb1f hl,,Ve septk' Cis 4t c}io6J-ye vj'-as nt-yer <br />I �„ 1VJ rT(C ?—"�I9°�f.r l bNCi f Q- Cf4ik/ICv, Ljo �'n1 ra �er�p��'r Fx.UIL_ JT�OG %ld'l ZL <br />PE <br />Code <br />SC Receiveeck#/ <br />INFO j BY CR sh <br />Amount <br />Remitted <br />Date Permit/ Invoice # Permit ID# <br />Service Request # <br />99d I <br />07S- h�Y( <br />9 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />