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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />6AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE /a <br />PERMIT GALL (ZU9 ] 'I 9553-7697 FOR INSPECTIONS / LXPIRRES YEAR FROM UATE ISSUE <br />JOB ADDRESS 1 a1 <br />' ��MI <br />_• -/ 4 'e_"� <br />1-[� i L)aily ka% CITY/ZIP <br />_ _ GC) /i r..4 - <br />CROSS STREET / y'�� ] ( APN O S 0 C/ 0 9 y PARCEL SIZE <br />1 <br />OWNER NAME (J/[�Q�� lJ-�NCLI/ VI / J� f :Y1C� C yec,i)(- 0 3'c%r 6u iq,� U6 PHONE <br />OWNER ADDRESS %637.3 i;Vl�bGirce,Cer0 dr) �P CITY/STATE/ZIP _S4,,4. LlP7 CSo?I cJ <br />CONTRACTOR CAM Id d� i�C-T7 PHONE d6q - / 7 U c� <br />CONTRACTOR ADDRESS 3 7 i � �ti,i14 e-, l� V• ` CITY/STATE/ZIP J ��/���� 114 1-wi 91 <br />LICENSE ❑)-42 [11:C-36 OTHER NUMBER7� LI EXPIRATION DATE 9/30 7Z <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ <br />PERC TEST # <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE <br />OF WORK: <br />❑ NEW INSTALLATION <br />) <br />REPAIRIADDITION ENGINEER DESIGNED /ALTERNATIV <br />►s <br />LL <br />REPLACEMENT kiI F 4 °e�f~^ 11 <br />OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION i"14: IG, /11, <br />INSTALLATION WILL <br />SERVE: RESIDENCE <br />❑ COMMERCIAL pe✓(LP) ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: Qh C I Ei NUMBER OF EMPLOYEES: <br />❑ <br />SEPTIC TANK <br />TYPE/MFG _C*,_*2[i /twx %/ek <br />CAPACITY )q z)o gal # OF COMPARTMENTS a <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 />:5_ " <br />XLEACH <br />LINES <br />U LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES 4k ft <br />DISTANCE TO NEAREST WELL /O© P <br />ft FOUNDATION— ` ft PROPERTY LINE A' ft <br />❑ <br />FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE 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 />�f <br />J8 <br />SEEPAGE PITS <br />DISTANCE TO NEAREST WELL <br />NUMBER WIDTH(i1 <br />ft FOUNDATION ft PROPERTY LINE ft <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ltQ! ft FOUNDATION !7C ft PROPERTY LINE L�b 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 <br />OF SAN JOAQUIN COUNTY. <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED zwx <br />TITLE64" i DATE <br />DEPARTMENT USE ONLY 1 G. Application Accepted By <br />ZZ— Date /a a�f .2 Area I "I Employee ID# rk <br />Final Inspection Byff� Date ?3 t 7 ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth A Ft: Pit/Sump Soil Character: <br />COMMENTS IJ»(YrtrrnnsNe j rCr _ L xl�1�n� J,�'46 - FuJ fP.d7lacemet7� �,-C <br />A' <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />CCheStW <br />ash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />9 DI ° <br />►s <br />(IY6 <br />_�3ia <br />S 0D19s0 --- <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />