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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 />IVUN-REFUNUAtlLE F'EKMIT <br />JOB ADDRESS 1 <br />CROSS STREET <br />L.ALL rLVJl JA.S-/D`J/ FOR INSPECTIONS tAPIRE5 T T EAR FROM <br />CITYIZIP A 1 y I,k)IV' 1/ tft- <br />APN o773-7oa7 PARCEL SIZE I as <br />OVVNER NAME <br />-rll <br />LEACHING CHAMBERS <br />PHONE <br />S <br />OVYMER ADDRESS(( <br />C4 <br />Ma <br />ft FOUNDATION <br />CITYISTATEIZIP <br />CONTRACTOR t.,/C', <br />❑ <br />�'�(j' 11-m <br />) C, <br />1 <br />PHONE Jy <br />CONTRACTOR ADDRESS <br />/V/,q� <br />_ �] TuL/ "r' <br />,. Jyp,/ <br />t V V �t-r1e D <br />•" <br />CITY/STATEIZIP Ju!_ 1. �a�/ / ✓�✓7 / <br />LICENSE xC42 <br />DISTANCE TO NEAREST <br />Cab OTHER <br />C� <br />�) <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 DESIGNED (ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: 'j( RESIDENCE COMMERCIAL OTHER <br />NUMBER OF LIVING UNITS: /(``vv'' �` `�h ..��11 d NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPEIMFG C/�-1 CAPACITY gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPFJMFG ' CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL R FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />LEACHING CHAMBERS <br />#OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />1 <br />SUMPS <br />WIDTH <br />ft <br />LENGTH <br />% d�� <br />ft <br />DEPTH l / ft <br />DISTANCE TO EAREST <br />WELL <br />S0 <br />ft FOUNDATION !D e <br />ft PROPERTY LINE r ft <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WOTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE R <br />I HEREBY CERTIFY THAT 1 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 JG-z'e TITLE 1��/� DATE :f5-- — 1� <br />) DEPARTMENT SE ONLY G /LLQ <br />Application Accepted By L` Date Area a -/ Employee ID# \� • <br />Final Inspection By A,45tt VIti Date - �- �-2 SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: PrdSump Soil Character: <br />COMMENTS nde+6r wtrn r E i -o 1 es o rema er <br />o -ver4 rri r' a /Or 1 I' ry r <br />kS . <br />PE SC Received -TheckN,,P Amount D Permitl Invoice # Permit ID# <br />Code INFO Remitted Service Reauest # <br />49 10 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />