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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 />INUN-rStFUry UAt3Lt F'ttKM11 L ALL (--Ub) VOJ-10V/ FOR INSPECTIONS tXPIHHLb 1 TEAH FROM DATE I55UEI <br />JOB ADDRESS _ 4'�/,p6. SID 5% LAr"m C. A? R� • q CIIT�Y ZIIP T R �-N 15' -11 <br />CROSS STREET py r`L-(.IIc 0 APN 2 I !-'To ) U PARCEL SIZE <br />e 23• �3 A' <br />OWNER NAME_ R+t� smI W -H PPHLONNEE (sio)�gm-0915- <br />OWNER ADDRESS ' 3 o a ✓AV STi N -c-r- CITY/STATE/ZIP g -E- • `o^11-1, C'A • 14 931) <br />CONTRACTOR L�dr OAK- &eVErJV 1"FVMCrN IAL PHONE Y& /` O3 1 S - <br />CONTRACTOR ADDRESS A4171 W O NK+ 5:1- CITY/STATE/ZIP <br />LICENSE ,-1.1.0-42 !J C-36 OTHER C E6- NUMBER Z) ) EXPIRATION DATE-4-30-2,2- <br />WATER <br />ATE4`30-22- <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />PERC TEST # <br />l BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEW INSTALLATION <br />REPAIR/ADDITION <br />ENGINEER DESIGNED/ALTERNATIVE <br />WIDTH <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL SERVE: J RESIDENCE <br />_! COMMERCIAL <br />- OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />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 />NUMBER <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />O PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES LEACHING CHAMBERS <br /># OF LINES <br />WELL <br />DISTANCE TO <br />NEAREST <br />❑ FILTER BED <br />WIDTH <br />LENGTH <br />DISTANCE TO <br />NEAREST <br />❑ MOUNDED <br />WIDTH <br />FOUNDATION <br />ft <br />DISTANCE TO <br />NEAREST <br />❑ SUMPS <br />WIDTH <br />ft <br />DISTANCE To <br />NEAREST <br />❑ DISPOSAL PONDS WIDTH <br />DISTANCE TO <br />NEAREST <br />❑ SEEPAGE PITS <br />NUMBER <br />ft <br />LENGTH <br />DISTANCE TO <br />NEAREST <br /># OF LINES <br />WELL <br />ft <br />FOUNDATION <br />It <br />LENGTH <br />WELL <br />ft <br />FOUNDATION <br />ft <br />LENGTH <br />WELL <br />ft <br />FOUNDATION <br />ft <br />LENGTH <br />WELL <br />ft <br />FOUNDATION <br />ft <br />LENGTH <br />WELL <br />ft <br />FOUNDATION <br />WIDTH <br />WELL ft FOUNDATION <br />LENGTH OF LINES ft <br />It PROPERTY LINE ft <br />ft DEPTH ft <br />ft PROPERTY LINE ft <br />ft DEPTH ft <br />ft PROPERTY LINE ft <br />R DEPTH ft <br />ft PROPERTY LINE ft <br />ft DEPTH ft <br />ft PROPERTY LINE ft <br />ft DEPTH ft <br />ft PROPERTY LINE It <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 />R gyMF <br />D E P A RE N /�ONLy <br />Application Accepted By LL Date <br />Area Employee ID#As 4� <br />, <br />Final Inspection By Date t�1\ }L\ 7 SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: N <br />D2 <br />COMMENTS NCppgR7��T <br />PE SC Received Check Amount Date Permit/ Invoice # Permit ID# <br />Code INFO B Remitted Service Request # <br />Nva sa3 ,els <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />