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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-FCEFUNDABLE VIERRMIT + GALL (LUy) &0J-/D&f FOR INSPECTIONS t=XPIRES 1 YEAR FROM DATE ISSUE <br />JOB ADDRESS 7 ` t- L1 I +� t' CITY/ <br />/ZIP , L <br />CROSS STREET 13 /i � APN 1-7 1 1 l 1 1f 14 PARCEL SIZEE� 60y L <br />OWNER NAME CS I \'�J` L—L-C 2 -PHONE I L /v� 7 Z/7�( � <br />OWNER ADDRESS PC) l3 t% 7� 7 CITY/STATE/ZIP ,`� �^ , I �� r S2U <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />LICENSE ❑I C-42 ❑.1C-36 OTHER <br />r <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER EXPIRATION <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: _: NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT -0F -SERVICE SEPTIC SYSTEM A DESTRUCTION 5Pp t I Lel Y1 k <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />❑ LEACH LINES LEACHING CHAMBERS <br />A] <br />DISTANCE TO NEAREST WELL <br />FILTER BED WIDTH ft LENGTH <br />DISTANCE TO NEAREST WELL <br />❑ MOUNDED WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />Date <br />❑ SUMPS WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />❑ DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />❑ SEEPAGE PITS NUMBER <br />WIDTH _ <br />DISTANCE TO NEAREST <br />WELL <br />CAPACITY <br />CAPACITY <br />ft FOUNDATION <br />❑ PKG TX PLANT <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br /># OF LINES <br />ft FOUNDATION <br />ft <br />ft FOUNDATION <br />ft <br />ft FOUNDATION <br />ft <br />ft FOUNDATION <br />ft <br />ft FOUNDATION <br />ft FOUNDATION <br />LENGTH OF LINES _ <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <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 />SIGNED <br />VI'C 1111JrG{s 1 IV/YJ-!-LC/iJC l,rF1LL LV.7 JJ.) -/VVI <br />TITLE n w K -z DATE ( I Zo u <br />�j DEPARTMENTUS ONLY <br />Application AcceptedRv CAV /�' Date 147 D Area Employee ID#� <br />Final Inspection By Date & — ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />PE <br />Code <br />Sc <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />'-I a a 1 <br />o-7 5- <br />Ise <br />' 2 .2 <br />SGZ oo m n- <br />42-01 /37653.201 <br />��Q J� ��� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />