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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 y� GALL (ZUy)Yb3-/b9/FOR INSPECTIONS tXPIHEGS I TEAH CHUM LJAIt Ibaut' <br />JOB ADDRESS 1-7 13 E• GIZE7L CT. . CITY/IZIP t2 ([,PaN IS3CQ& I_ y <br />CROSS STREET .�nVJ 1°( 6-A J E (2- APN 2-4' - - otvD - 3a PARCEL SIZE <br />L; Z • 1 U! 11c- <br />OWNER NAME IM OkRC i3E9-TSCtA PHONE (YV5-- J.2-31+ <br />C/o BVIL_OGIZS <br />OWNER ADDRESS ���1— M iIiJ STS STE• 0 CITY/STATE/ZIP Rl (�D N C A c/ 5 3" <br />CONTRACTOR (-)JE QA)G GLOENVYYZONfV\Enu- (it L- PHONE :?Coq 03i) <br />CONTRACTOR ADDRESS `fD`I w - D A K 5-1-- CITY/STATE/ZIP L -DD l C-^ �el'� <br />LICENSE 11.1C-42 11 C-36 OTHER C L NUMBER Z (S ( EXPIRATION DATE `-f -3o -1 T <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />PERC TEST # <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />I NEW INSTALLATION j <br />REPAIR/ADDITION <br />Li ENGINEER DESIGNED/ALTERNATIVE <br />ft FOUNDATION <br />! I REPLACEMENT f. i <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />I.: DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ MOUNDED <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />CI LEACHING CHAMBERS <br />Check#/ Amount <br />ate <br /># OF LINES <br />Code <br />LENGTH OF LINES ft <br />Cash Remitted <br />DISTANCE TO NEAREST <br />WELL <br />3 <br />ft FOUNDATION <br />ft PROPERTY LINE ft <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 It <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 />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH SP <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH W <br />DISTANCE TD NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE It <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. j-1 r--:, I <br />'AYMEN <br />tECEI i/ Ef;,:+ <br />i U G 18 202? <br />JOAQUIN COUNTY <br />WIRONMENTAL <br />LTH DEPARTMENT <br />DEPARTMENT USE ONLY <br />`SI <br />Application Accepted By Date Area �- G / / Employee ID# <br />Final Inspection By Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to(o"� Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS rr i l��'I� &I? KJoY'l73� <br />PE <br />SC Received <br />Check#/ Amount <br />ate <br />Permit/ Invoice # Permit ID# <br />Code <br />INFO B <br />Cash Remitted <br />Servic Re uest # <br />u d a <br />3 <br />a r <br />o0o i <br />4,� <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />7 �J 1 1 VV � U4 <br />18 2022 <br />JEINTAL HEALTH <br />USERVICES <br />