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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 y L <br />CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS b" <br />j S Aj <br />Ire <br />CITY/ZIP <br />gal # OF COMPARTMENTS <br />FOUNDATION V ft PROPERTY LINE 5 ft <br />� <br />/� `� <br />01-7 d iZ)da Cf.dc <br />CROSSSTREET <br />J11 <br />c C_ <br />APN PARCELSIZE <br />OWNER NAME <br />DISTANCE TO NEAREST <br />S►Jr <br />11n <br />Ct = ��" T T` n ��►%M 1 PHHONE <br />❑ <br />Q <br />Pb 6Sx <br />II So <br />ft LENGTH <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />CONTRACTOR j_'e,017AG <br />I'yL low/'''v <br />❑ <br />_sc .-/7 PHONE 36,9- <br />CONTRACTOR ADDRESS 37416 <br />�"I ItCIC-1 <br />7 <br />CITY/STATE/ZIP <br />Y/%/��/ <br />LICENSE ❑X-42 <br />❑CIC -36 OTHER <br />y�/�� <br />NUMBER / /C��S EXPIRATION DATE U VZ'Z <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # o? 10,;? O Soo LAND USE APPLICATION # <br />TYPE OF WORK: 127 NEW INSTALLATION CI REPAIR/ADDITION [I ENGINEER DESIGNED /ALTERNATIVE <br />❑ REPLACEMENT ❑ OUT -0F -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: Z<RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: S NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG y L <br />CAPACITY �cTUG <br />gal # OF COMPARTMENTS r� <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />FOUNDATION V ft PROPERTY LINE 5 ft <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION �� ' <br />ft PROPERTY LINE ?S' ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />IB- <br />LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES 3 LENGTH OF LINES S -S / ft <br />Amount <br />Remitted <br />Date <br />DISTANCE TO NEAREST <br />WELL / ,�10 ft <br />FOUNDATION V ft PROPERTY LINE 5 ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />ok—t <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 <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />FOUNDATION ft PROPERTY LINE ft <br />SEEPAGE PITS <br />, //ft <br />NUMBER 3 WIDTH _/V , ft DEPTH ;;?-S ft <br />DISTANCE TO NEAREST <br />WELL %5U ft <br />FOUNDATION PROPERTY LINE I S_ 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 />IvIlIVIIVIVIVI Yo "L.IVIA 14U VM IV LIC IV I Ilic RC VII%CL/ I-Vr[ 11V0r-V_%' I IVIVJ - rLCIiJC (cvo Fav -I o.7I <br />SIGNED ��'` — TITLE DATE / <br />DEPARTMEN U E ONLY ryTO ' <br />Application Accepted By Ili q% Z Date S f 9 a� Area q Employee ID# ;FN' <br />Final Inspection By Date ~�� ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS NeW SFR. /Jon- rep AIr '�i¢r 1 There McAll be 90001 Well 6n ar fny <br />f i+ - 8+6 <br />yhafyk l� r c�Q a o� /Ie�„> •� �6 -8�o f✓ A� <br />PE <br />Code <br />Sc <br />INFO <br />Receivedhec <br />By <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />qd11 <br />117 <br />ok—t <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />T <br />