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T <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 HERMIT <br />❑ <br />GALL LUY 90J -16y/ FOR INSPECTIONS <br />t_XPIRESYEAR FROM DATE ISSUED <br />I <br />JOB ADDRESS 5 <br />`E - <br />% G > CITY/ZIP <br />/, <br />v C1 5 aa <br />CROSS STREET I-�rp'V��1l�c <br />y <br />161 - APN (20 � — 2 % �7 <br />j <br />0 � "T PARCEL SIZE � Ae°C <br />OWNER NAME / S W`%O <br />�j15, <br />IBJ/CCG��C� <br />PHONE <br />OWNER ADDRESS CITY/STATE/ZIP <br />CONTRACTOR /amc PHONE ;26;F �5_Q7 <br />CONTRACTOR ADDRESS 3 7 /' (e --k. 44 if /�' CITY/STATE/ZIP �j ✓ ��'� / �'/i ( �' <br />LICENSE 0 4 ❑❑C-36 OTHER NUMBER�EXPIRATION DATE ( _ 3f —,9-? <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ <br />PERC TEST # BUILDING PERMIT;'# LAND USE APPLICATION # <br />TYPE OF WORK: 10 NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNA IVE <br />Service Re uest # <br />REPLACEMENT e El OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION 14 44 <br />INSTALLATION <br />WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL O HER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:`` NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG v� CAPACITY (49OCL gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL—60 ft FOUNDATION ft PROPERTY LINE s ft <br />❑ <br />LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES 5i5 ft <br />tvLEACH <br />DISTANCE TO NEAREST WELL__,,/06 ft FOUNDATION fO ft PROPERTY LINE 00 ft <br />❑ <br />FILTER BED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />MOUNDED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SUMPS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL FOUNDATION ft PROPERTY LINE ft <br />(ftf <br />SEEPAGE PITS NUMBER WIDTH / `/ ft DEPTH C9 _ ft <br />II! <br />DISTANCE TO AREST WELL �ao , ft FOUNDATION v�O ft PROPERTY LINED 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 ADVANCE ALOTICE REQUIRED FOR INSPEC IONS -- PLEASE CALL 209 953-7697 <br />SIGNED <br />14.6 TITLE DATE <br />Application Accepted By Date <br />Final Inspection By Date <br />Character of Soil to epth f 3 Ft: <br />COMMENTS r <br />JSVL ONLY <br />Area Employee ID# <br />/ D ❑ SPECIAL PERMIT -Approved by <br />Pit/Sump Soil Character; <br />;.UP E/' i�>1 Q , <br />PE Sc Received Check#/ Amount <br />at Permit/ <br />Invoice # Permit ID# <br />Code INFO Cash Remitted <br />Service Re uest # <br />42-01 <br />4/14/18 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />