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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAh JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT s CALL (209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI <br />4j 5y el <br />JOB ADDRESS LV l �[ - nVe <br />Q CITY/ZIP 1/ iiX�ptlj <br />CROSSSTREET O sC L _lnt_ ',IG AP 360 - 54 PARCEL SIZE 2,0 <br />OWNER NAME_ _�iv7 G ve T' yu VV- PHONE 7,0 y �� 3- L�Z <br />OWNER ADDRESSf�1 CITY/STATEIZjIP <br />CONTRACTOR //"LenzPHONE <br />CONTRACTOR ADDRESS 37V4 ;W.,/C. <br />CITY/STATE/ZIP <br />LICENSE ❑y,-42 ❑ I C-36 OTHER NUMBER % S/V L EXPIRATION DATE0%/ "3 <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # "22D2 - Y -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: IW -RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: -3 NUMBER OF EMPLOYEES: <br />II, SEPTIC TANK <br />TYPE/MFG e'ltL <br />CAPACITY gal <br /># OF COMPARTMENTS Z <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal <br /># OF COMPARTMENTS <br />DISTANCE TO NEAREST <br />DISTANCE TO NEAREST: WELL /011::� ! <br />ft FOUNDATION 5 ft <br />PROPERTY LINE ft <br />10 LIFT STATION <br />SIZE aHP TYPE OF PUMPLL I� <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />IIS <br />LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES j <br />LENGTH OF LINES <br />ft <br />Invoice # <br />DISTANCE TO NEAREST <br />WELL ,J/D ft <br />FOUNDATION / Ci <br />ft PROPERTY LINE <br />ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />CiL <br />SEEPAGE PITS <br />NUMBER 3 <br />rift <br />WIDTH Yy <br />11 ft <br />DEPTH 5 <br />ft <br />DISTANCE To NEAREST <br />WELLs� ft <br />FOUNDATION <br />ft PROPERTY LINE <br />— _ 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 TITLE DATE <br />Application Accepted <br />Final Inspection By T. S� <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS( Pmvoded G <br />twil <br />DEPARTMENT U E QfNLY <br />¢_ Date 3 22 Area ` <br />Date � 4.2 ;e-_ ❑ SPECIAL PERMIT - <br />Pit/Sump Soil Character: <br />Employ%%P,# Ik S, <br />JOS <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Cash <br />Amount <br />emitted <br />Permit/ <br />ate Service Request # <br />Invoice # <br />s( o a- I15 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />r <br />