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0 <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 <br />NON-KEFUNDABLE /Y�ERM I7 / <br />JOB ADDRESS ��l / & 1 <br />CROSS STREET II l 9 APN q 3 - 0 b - 63 , (0 1- -PARCEL 4CEEL SIZE 5. 1 GLC' <br />OWNER NAME �1 V � nY' R \'i PJ(O- PHONE0Ii / )l R`7 k <br />OWNERADDRESS SSD M, Hew%'44 Rce,n . CITY/STATE/ZPnp \1�1/KJ, IPiV�/�_(A' `, CjL�. <br />P <br />CONTRACTOR - /JPHONE I a 11 <br />CONTRACTOR ADDRESS Flo J 9A 1( 'T I / GL) 77 CITY/STATE21P LA I, Ulm. qSl�� <br />LICENSE LI -C-42 ❑ _C36 OTHER RG V NUMBER .CJN0 1 EXPIRATION DATE 09 - So —11 <br />WATER TABLE DEPTH: { SCS It GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # LI <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION � ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPEIMFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />I LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />It PROPERTY LINE <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <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 />ADVANCE N <br />TI E REQUIRED <br />FOR INSPECTIONS - <br />LEA E CALL(2 953-762 <br />SIGNED <br />TITLE 5-,S <br />9 <br />DATE <br />Application Accepted <br />Final Inspection By <br />/0111 <br />Character of Soil to -'Alep of 3 <br />COMMENTS l I -D -y'- <br />PE SC Receivec <br />Code INFO B <br />J22 S -Z 3 01 <br />42-01 <br />4/14/18 <br />4. <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />It <br />ft <br />ft <br />ft <br />ft <br />ft <br />ki <br />l <br />PL <br />1■■■■■■■■■691 . . <br />DEPARTME TT SONLY <br />Date L Area <br />DateS (Z ZZ ❑ <br />z S�1Y ►.�,u 1 .n C7 'i <br />#I Invoice # <br />Permit ID# I <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />