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I <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-KEFUNDABLE F'ERMI1 <br />GALL (ZUy) YOJ-10YI FOR INSPECTIONS LXPIRES 'I YEAR FROM DATE ISSUE. <br />JOB ADDRESS ' V / 11O 0 w Ki- 1pQN Eb ll cc CITY/ZIP e tON M " 7 3,5 t (j <br />CROSS STREET AIAt1-A- APNdj- N0 PARCEL 6 a��PARCEL SIZEJ - ) 4a-'� <br />OWNER NAME } es & ML4• e4f /-4 y�PHONE �Jds 5"d 'aus <br />OWNER ADDRESS / jj ply% W k i- PON An CITY/STATE/ZIP It ) pom <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />LICENSE ❑ C-42 ❑ "'C-36 OTHER <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ <br />PERC TEST # <br />BUILDING PERMIT # <br />g 'a,),O I jb 7 LAND USE APPLICATION # <br />TYPE OF WORK: <br />1 NEW INSTALLATION <br />REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ <br />SEPTIC TANK <br />TYPE/MFG Covl� I n L <br />GjL <br />CAPACITY / (;QQ gal #OF COMPARTMENTS C�_ <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH 3Q' ft LENGTH <br />35 ft DEPTH '301, ft <br />tic, <br />DISTANCE TO NEAREST WELL O , ft FOUNDATION ft PROPERTY LINE O ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION 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 />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED <br />TITLE DATE <br />DEPARTME T USE NLY <br />Application Accepted By / Datq( Area 7 Employee ID# <br />Final Inspection By Date — 702-7 ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 F : Pit/Sump Soil Char cter: <br />COMMENTS �� L) n r? -- <br />Inn A) n, 1i�f� Pin 1 /0-A i. YtX..Q r ?--oOi7 a ct,If mil <br />-� „A Gi c n o lnT, ,d�" l' r� C -P jQi?r 2_1A).r.,-1WA0- <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ Amount <br />Cas�t RemitteP, <br />to Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />