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t <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVUN-1111=11-UNDABLE PERMIT /JL;AjLL LUy 'JS:f-16.91 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS 1 1 H[� CITY/ZIP <br />1 - � <br />CROSS STREET APN 10 1 , S PARCEL SIZ/E <br />OWNER NAME l/,���/^ A A' � PHONE iL9% J <br />LI�Q <br />OWNER ADDRESS �<",AA-&4 / G CITY/STATE/ZIP <br />CONTRACTOR)���(�f) % [�1I/��%/�/� �jL�• PHONE C*,*' <br />CONTRACTOR ADDRESS / !J �'� 7" G 17 ji1/(/ �{, h CITY/STATE/ZIP �f/O� V%c����/� 6A <br />LICENSE ❑❑C-42 110C-36 OTHER NUMBER L1 �_S EXPIRATION DATE "U �.T� Z2 <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />FEF PERC TEST # BUILDING PERMIT # d O 0 1,3 %O LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: Ld NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY <br />CAPACITY <br />DISTANCE TO NEAREST: WELL ft FOUNDATION _ <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES V0 y ft <br />DISTANCE TO NEAREST <br />WELL S D i" ft <br />FOUNDATION / L� -F• ft PROPERTY LINE , ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />SEEPAGE PITS <br />NUMBER, <br />WIDTH 3 <br />ft DEPTH j^ ft <br />DISTANCE TO NEAREST <br />WELL ZLW ft <br />) <br />FOUNDATION AQ " � ft PROPERTY LINE -,I� 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 />SIGNED <br />VR /►YJr-G;L, I 1YJ - P'LCNJC I.ALL I LUyI JA3-/OJ/ <br />TITLE DATE <br />NT <br />2021 <br />;OUNTY <br />NTAL <br />.77. DEPARTMENT USE ONLY I (` I, <br />Application Accepted By ��-�-� Date /J / Area Employee ID# rfC,V1 K %. <br />Final Inspection By Date �D`Z-1L ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTSL11QI�I1C�I }�o►� e.��1 n� �Psi� L�i9C(. aeT RF -a 009970 , UC- n«Cj(j- 1 -J0;7k / beC)r�/11- <br />i'�q�e'� Sq�LelCKs 1pP.xl i�,rl� IIY►Pti L' `rl }l� JJt >� exlsl1 y5'{P]yl <br />PE SC Received Check#/ Amount ate Permit/ Invoice # Permit ID# <br />Code INFO B Cash Remitted Service Request # <br />d10 115` *30o7 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />