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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-MttUNUAtSLt 11EKMI I <br />(;ALL ZU,9 ,9b.f-115,9/ FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUE <br />JOB ADDRESS )-375.1 <br />5) /1 D RQAt) <br />CITY/ZIP Z <br />'5 Q <br />/ELV ' /SQ� <br />CROSS STREET 4-O'V <br />/[ur <br />O,d %% <br />q <br />AP .1 �Q - /('O�� S <br />PARCEL SIZE a / ' 83 <br />OWNER NAME & L /FoZN/,A <br />2 <br />\1A 2 Q 5, L /_ G <br />ft LENGTH <br />PHONE .5-/0 - 63 0 - o (bQ <br />ft DEPTH ft <br />OWNER ADDRESS a0Q4 <br />f e.4 E STR-,65E1- <br />CITY/STATE/ZIP <br />5AN LEAdD 20rA q¢57-7 <br />/0' <br />CONTRACTOR(. 1 t G�JIy�I CY <br />. <br />`D /� suL T/�/C <br />PHONE <br />WIDTH <br />CONTRACTOR ADDRESS I <br />ao)!C <br />CITY/STATE/ZIP <br />U LLQ6e CA 53 r <br />LICENSE ❑0C-42 ❑❑C-36 <br />OTHER CE <br />NUMBERt:7'7 4-16 EXPIRATION DATE <br />ft <br />WATER TABLE DEPTH: SD ft GEOGRAPHICAL INFORMATION <br />PERC TEST # I BUILDING PERMIT # <br />TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADI <br />Coordinates X <br />LAND USE APPLICATION # <br />IN ❑ ENGINEER DE <br />L] REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION <br />Y <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 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 />TERNATIVE <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />I <br />ft <br />❑ LEACH LINES <br />❑ LEACHING CHAMBERS <br />Received <br />By <br /># OF LINES <br />LENGTH OF LINES ft <br />ate <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />L <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE. ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />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 />1-1 STATE LAWS AND RULES AND <br />REGULATIONS OF SAN JOAQUIN <br />COUNTY. <br />SIGNED <br />vn 11v.2rc%. Iwr�r/o/- r�crSoc �.fSL� tcV: <br />TITLE DATE <br />W <br />EPA RTMENT USE ONLY <br />Application Accepted By Date Area fq Employee ID#_As <br />Final Inspection By s Co n- Date W❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />ate <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />Z3 <br />_Z <br />L <br />.61 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />