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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-REFUNDABLE PERMIT <br />TYPE/MFG <br />GALLL <br />"109 953-7697 FOR INSPECTIONS <br />t 1 YEAR FROM UATE ISSUEI <br />JOB ADDRESS 7 <br />�% 0 <br />"'Ty'r G N /-D <br />CITY/ZIP <br />�3 <br />CROSS STREET ` �r <br />/ P <br />APN '2- <br />z S-0 <br />`O <br />- PARCEL SIZE 7 <br />//J <br />OWNER NAME .JL / <br />_ <br />�e��WV <br />1 <br />ft PROPERTY LINE ft <br />PHOd2`C' Z Tori% <br />OWNER ADDRESS � � �� <br />AL1 Vl) <br />L 1 '0 <br />❑ <br />CITY/STATE/ZIP <br />❑ LEACH LINES <br />CONTRACTOR A /1'11674 <br />�� ' t <br />` <br />J/e <br />y <br />PHONE—/� 1 3 1 <br />CONTRACTOR ADDRESS ( `w <br />!� ��/�✓ <br />L `"� <br />v <br />CITY/STATE/ZIP <br />i'�/ci/-� TJ -3 <br />LICENSE ❑' ,C-42 ❑ C-36 OTHER <br />NUMBER -?/J <br />EXPIRATION DATE <br />WIDTH, <br />L <br />ft LENGTH <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION A REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: ` RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />Received <br />B <br />(Check#P <br />CAPACITY <br />Date <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />L-1 <br />CAPACITY <br />gal # OF COMPARTMENTS <br />- 12- <br />DISTANCE TO NEAREST: <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINEs <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />® FILTER BED <br />WIDTH, <br />L <br />ft LENGTH <br />-S--o <br />ft <br />DEPTH � Lid 1�hGYr,� ft <br />DISTANCE TO NEAREST <br />WELL �GD 0 ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE 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 />WHIVIMU 40 ri Liu'C HU VM1VL1G Ivw I1L V- r[G V11[CLJ rV1[ /IY.7rCl1 I IV/Y0 - rLCF101-_ %,.MLI.- 1,CVVj VUJ-1 UVI <br />SIGNED ; TITLE �� . ^ I<, �� DATE �5 2"_17v 0 IL <br />DEPARTMENT USE ONLY <br />Application Accepted By ��O A Date 5 Area ' �C� Employee ID# <br />Final Inspection By &- Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 A Pit/Sump Soil Character: <br />COMMENTS Uncle W kr llf). . Tier .-a e. XIShp j hy)e.s to femGo!h, <br />PE <br />Code <br />Sc <br />INFO <br />Received <br />B <br />(Check#P <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />L-1 <br />43 -Do <br />- 12- <br />`3fZ 0) ��. <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />T <br />