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f 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 (;ALL (ZUY) Yb f -/(i9/ FOR INSPECTIONS tXPIRES 'I YEAR FROM DATE ISSUE <br />JOB ADDRESS ����! /�j� elyl��v �/lw /] CITY/ZIPS^ �_Uci <br />CROSS STREET P��(,lr,/ APN (//"U�� 7 V PARCEL SIZE <br />OWNER NAME,Bli�r ��aG/eQ01 PHONE_ -10k- <br />OWNER <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />CONTRACTOR e:_"1xnz_ JJP// 711C4/_ G� , PHONE 30%1-5_0Z-7 <br />CONTRACTOR ADDRESS -9�7b lJ C1� /� I��- CITY/STATEIZIP 5k_L <br />LICENSE ❑ 1 -42 DOC -36 OTHER <br />NUMBER y5'10 fS EXPIRATION DATE D_1,1Z 7 -- <br />WATER <br />> Z7 -- <br />WATER TABLE DEPTH: v ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: C! NEW INSTALLATION I . REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT fAl%k I l i„es J OUT -OF -SERVICE SEPTIC SYSTEM A DESTRUCTION -SephZ <br />INSTALLATION WILL SERVE: VRESIDENCE ❑ COMMERCIAL pey Purce ❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: 8 d V -G0er NUMBER OF EMPLOYEES: <br />ei- SEPTIC TANK <br />TYPE/MFG£ �.- <br />CAPACITY jZC�C� gal <br /># OF COMPARTMENTS_ <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal <br /># OF COMPARTMENTS <br />❑ <br />DISTANCE TO NEAREST: WELL ja?O +4 <br />ft FOUNDATION ft <br />C <br />PROPERTY LINE 77 ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL <br />SEPARATOR (ENCLOSED SYSTEM) <br />1rx <br />LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES <br />4V <br />ft <br />Amount <br />RemittedService <br />/ <br />DISTANCE TO NEAREST WELL ft FOUNDATION SC) ft PROPERTY LINE <br />Jd <br />ft <br />❑ <br />FILTER BED WIDTH ft LENGTH ft DEPTH <br />►is <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED WIDTH ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ <br />SUMPS WIDTH ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />SEEPAGE PITS NUMBER 21 WIDTH .361. ft DEPTH 495-' <br />ft <br />DISTANCE TO NEAREST WELL_Z&00ft FOUNDATION D ft PROPERTY LINE <br />/ <br />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 />MINIMUM 48 HOUR -ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 <br />953-7697 <br />SIGNED TITLE DATE <br />AYA <br />r <br />A <br />R N vro <br />pRT <br />✓�rnn n�r v � vrv� I// <br />Application Accepted By Date S /!a 9 a Area Employee ID# 14 V <br />Final Inspection By. Date �(.l l� `L2 ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 t: Pit/Sump Soil Character: <br />COMMENTS Unfe(MMe . I >er goUSe heig tW o -Sepf<< SYSeMS. roll rep/tic e merit 0 <br />ane s)54em , Pft �fAw► Coorc,161kiDr okc'yed rep>a� yj )'Aouf city ✓e/1(4. -j%)7 6r w0$S1'b10 <br />sender c/annecfion. <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />C e <br />Cash <br />Amount <br />RemittedService <br />Date <br />Permit/ <br />Request # <br />Invoice # <br />Permit ID# <br />'1310 <br />►is <br />jw3a� <br />22 <br />Wh <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />