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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 PERMIT <br />L ALL ZUJ V0J-f0Y/ FOR INSPECTIONS <br />LXPIRES FROM UATE ISSUEI <br />JOB ADDRESS 16443 <br />b1 ee7T-9AN�(j2 <br />&Amo,A( DK• CITY/ZIP 72 Ac•/ <br />/IjYEAR <br />_ CA 9570.4 <br />CROSS STREET <br />�RuNr4uER <br />n <br />APN v2©!f ^ 3 !4y — ar <br />PARCEL SIZE / 0 9Ae. <br />OWNER NAME =:ro <br />FI iN <br />SIZE TYPE OF PUMP <br />PHONE <br />O SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />NEAREST WELL <br />OWNER ADDRESS <br />wm, F <br />CITY/STATE/ZIP <br />WIDTH <br />CONTRACTOR 1Q/'/ <br />/ f _ / <br />1 G X u%T1 /Y � PHONE �1 <br />6-5PP-1150X <br />1P.9 - /./ 5121 <br />CONTRACTOR ADDRESS 1 • D• <br />V1,^QA15 <br />F50X # CITY/STATE/ZIP <br />�&RL-Pee- eA 2-k2V <br />LICENSE L'' C-42 <br />Ll C-36 <br />�jgzf <br />OTHER RGE NUMBER75472 EXPIRATION DATE/30/aa <br />WIDTH <br />ft LENGTH <br />W TER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE C COMMERCIAL L OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />O SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO <br />NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO <br />NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO <br />NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO <br />NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO <br />NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO <br />NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />I HEREBY CERTIF I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />'HAT <br />J <br />STATE LAWS AND RULES AND <br />REGULATIONS OF SAN JOAQUIN <br />COUNTY. <br />MI IM 48 <br />A <br />VANCE NOTICE REQUIRED <br />FOR INSPECTIONS <br />- PLEASE CALL 209 953 769 <br />SIGNED <br />TITLE C/1(� <br />DATE <br />DATE <br />Application Accepted <br />Final Inspection By_ <br />Character of Soil to D <br />COMMENTS <br />3 Ft: <br />Date <br />Date <br />N L Y 'AS- <br />nae- <br />� <br />'Z` Area ` Employee ID# <br />n L ❑ SPECIAL PERMIT - Approved by <br />p Soil Character: <br />PE SC Received <br />Code INFO <br />Check#/ Amount to <br />Cash Remitted <br />Permit]Invoice # Permit ID# <br />Service Request # <br />Z2 2 <br />0�� 1l0 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />G <br />