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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-KEFUNDABILEt PERMIT <br />-Y GALL LU`V0J-/0Vf FOR INSPECTIONS tXPIRES 1 TEAR ROM DATE ISSUI <br />� <br />JOB ADDRESS 2y�"�1 < Ty`Qc\k <br />n. /�C <br />CmIZIP - �O <br />TYPE OF WORK: <br />NEW INSTALLATION q:.—REPAIR/ADDITION <br />Q <br />� —�2 <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM <br />CROSS STREET 1 t 1 Z1'Q/��� O CSA <br />APN <br />I OTHER <br />PAR\C[EL SrLE �a <br />OWNER NAME` <br />E( SEPTIC TANK <br />W' <br />PHONE <br />981 # OF COMPARTMENTS <br />OWNER ADDRESS `U�.� �t�..L <br />a b%\'re` - <br />CITY/STATEIZIP <br />CONTRACTOR W C�{��J 1 <br />�aG1 �`{` O <br />PHONE uC-i(� G <br />1�� ��� / y <br />CONTRACTOR ADDRESS 1! 1 ��C i (\ V � • <br />CRY/STATEILP I—� � <br />r <br />rAV t aJ 2'-"y O <br />LICENSE _. C42 C36 OTHER <br />.2_ NUMBER EXPIRATION DATE • LIJ-2-:b <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />PERC TEST # <br />BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEW INSTALLATION q:.—REPAIR/ADDITION <br />ENGINEER DESIGNED /ALTERNATIVE <br />Final Inspection <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE i COMMERCIAL <br />I OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />E( SEPTIC TANK <br />W' <br />TYPE/MFG CAPACITY C' <br />981 # OF COMPARTMENTS <br />O GREASE TRAP <br />TYPE/MFG CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL f1 FOUNDATION <br />ft PROPERTY LINE ft <br />0 LIFT STATION <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />M' LEACH LINES <br />1 <br />LEACHING CHAMBERS \t�� 1 I tea-' # OF LINES , <br />LENGTH OF LINES 5 y R <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH ft LENGTH It <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH ft LENGTH R <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH 11 LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />SEEPAGE PITS <br />NUMBER Z WIDTH 3 <br />ft DEPTH -2—'5- ft <br />DISTANCE TO NEAREST WELL.404ft FOUNDATION <br />ft PROPERTY LINE ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE <br />WITH SAN JOAQUIN COUNTY ORDINANCES, <br />'*MWM <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />PLEASE CALL (209) 953- <br />48 <br />SIGNED <br />H04& FOR INSCgCTZQB� <br />TITLE Q�lYti .� <br />DATE -?:>M �PQ— <br />1 2022 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />•D PARTMENT <br />S ONLY �� <br />Application AccZI <br />Date <br />ytJ Area Employee ID# Q : Lw � <br />y ��( <br />"041 <br />Final Inspection <br />Dte <br />Z- SP IAL P RMIT - Approved by <br />Character of Sol <br />PO/Sump Sol[ Character: <br />COMMENTS <br />f-4NV,W.) <br />PE SC Received <br />_ . _ _ <br />Amount <br />_ .. 'Date <br />Permit/ <br />Invoice# PermitlD# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />