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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-KEFUNDABLE VERMIT (:ALL LUY Y5DJ-/0y/ FOR INSPECTIONS tXPIRESS 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS �D� �Iv��RV t C <br />S CITY/ZIP /� <br />CROSS STREET f /�/)y� %'L AP O D — Lo ~ PARCEL SIZE er <br />OWNER NAME /Vl y'mlef-� Ra'n u'e7.,- PHONE 20- - 1 /02--� / / <br />OWNER ADDRESS Q& Zl (l/Gty CITY/STATE/ZIP S�Gk-1C0)-L <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE ❑ C-42 ❑ C-36 OTHER <br />NUMBER EXPIRATION DATE <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 ENGINEER DESK <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />TERNATIVE <br />❑ <br />SEPTIC TANK <br />TYPE/MFG <br />Amount <br />Remitted <br />CAPACITY <br />gal # OF COMPARTMENTS <br />Invoice # <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />Z'0 <br />CAPACITY <br />gal # OF COMPARTMENTS <br />S 00&s2H J <br />DISTANCE TO NEAREST: <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES� <br />LENGTH OF LINES <br />ft <br />✓✓✓ ��\ <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION W 1()'-( ft PROPERTY LINE S <br />ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE <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 />VIA IIYJ!-LV I IV I11J - rLL/-1JL VMLL ILVJf !: VJ/ <br />TITLE DATE 5- 6 - 2 Z <br />T <br />D PARTMENT S ONLY <br />Application Accepted Byd Date Area Employee ID#A1.Awg0 <br />Final Inspection By Date L7 _p �� ❑ SP IAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS �ZI , UIUCYLs� (/( 1 A?,��7< .&4r .& !LAak -cAdm Lm4Fz <br />PE <br />Code <br />SC <br />INFO <br />Received Check#/ <br />B Ca <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />Z'0 <br />0 6 <br />6 -(J -z2 <br />S 00&s2H J <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />