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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 HERMIT <br />'GALL ZU9 953-7697 FOR INSPECTIONS <br />JOB ADDRESS $U:ytom (` Jt Z - If a CITY/ZIP_ <br />1� <br />CROSS STREET �Yl�1 11 n CA APN 3 -1 2Tf ') 1 C) <br />EXPIRES 1 YEAR FROM DATE ISSUE <br />;"KC C' j <br />%� <br />�j PARCEL SIZE 1 I <br />� <br />OWNER NAME -rGrp3 9or1G1d SOiC*D PHONE <br />OWNER ADDRESS -sewe 1 ` L �` CITY/STATE/ZIP <br />CONTRACTOR p/f/�O�1E S{�D� i�� S��e/ PHONE 2 C1 S / <br />CONTRACTOR ADDRESS V1 > `i I ��/V ��� �-�% �//` / CITY/STATE/ZIP <br />LICENSE ❑ 1 iC-42 ❑ C-36 OTHER 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: i NEW INSTALLATION / REPAIR/ADDITION ENGINEER DESIGNED/ALTER ATIVE <br />ai REPLACEMENT �/}� `� OUT -OF -SERVICE SEPTIC SYSTEM 4F DESTRUCTION 7`/11r <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL El <br />ElOTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: -i NUMBER OF EMPLOYEES: <br />M <br />SEPTICTANK <br />TYPE/MFG f/ <br />f±�� C —XX4 <br />CAPACITY /Citi J gal #OFCOMPARTMENTS <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />Permit ID# <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />10 <br />LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES <br />DISTANCE TO NEAREST <br />WELL coo , ft <br />FOUNDATION Z O I <br />ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />SUMPS <br />WIDTH L <br />ft LENGTH <br />/ 6, ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ZS -y ft <br />FOUNDATION $ vt <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL 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 />SIGNED <br />VR IIVaJr I. -{„i I /V111YJ - rLLF1JC VMLL 4t/z' JJJ <br />TITLE ��^ 7�/a �1t/i` DATE S <br />r <br />1 Z✓z-� <br />_r—� / DEPARTMENT U E ONLY <br />Application Accepted By G /�� Z-/-- Date S I! a? Area Employee ID# <br />Final Inspection By ILM�aC Date S 'iC3Z 2 ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS UfideTMI' n -ea(, 7;-er j -r, -'emolin <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Chec <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />