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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-KEFUNDABLE F'ERMIJ <br />(:ALL (ZUy),90J-/by/ FOR INSPECTIONS CXPIRES "I YEAR FROM DATE ISSUE <br />JOB ADDRESS T� SSS /9YIZGhC12UIa/G CITY/ZIP 1/PICA--*J 77�� <br />CROSS STREET U Ot �P/) C I APN D 9Iy ' LIPARCEL SIZE '1'1 <br />OWNER NAME m�/� C�C� S1n0 ( KW- 1'G PHONE��(j� <br />OWNER ADDRESS// CITY/STATE/ZIP C, <br />CONTRACTOR Z4 /x^ ��r[/ C. y� PHONE 5-6 Z7 <br />CONTRACTOR ADDRESS37y�OV1(J»1N yi///C 12 CITY/STATE/ZIP/OGS <br />LICENSE OA- -42 ❑ `C-36 OTHER <br />NUMBER 7 SJD Y-� EXPIRATION DATE O tAZ <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: LI NEW INSTALLATION V, REPAIRIADDITION I_ ENGINEER DESIGNED <br />I I REPLACEMENT I I OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAALer �p��� ElOTHER <br />NUMBER OF LIVING UNITS: l NUMBER OF BEDROOMS: i Vi cif r NUMBER OF EMPLOYEES: <br />TERNATIVE <br />❑ <br />❑ <br />❑ <br />SEPTIC TANK <br />GREASE TRAP <br />LIFT STATION <br />TYPE/MFG _�C/S� IIS CAPACITY � gal # OF COMPARTMENTS <br />TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL 5"O f- ft FOUNDATION /Q ft PROPERTY LINE So r ft <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />ISI <br />LEACH LINES <br />U LEACHING CHAMBERS <br /># OF LINES / LENGTH OF LINES5` ft <br />Invoice # <br />Permit ID# <br />DISTANCE TO NEAREST WELL /SO t ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL/� ft <br />FOUNDATION ft PROPERTY LINE ft <br />SEEPAGE PITS <br />NUMBER�y" <br />WIDTH O„ <br />ft DEPTH �S ft <br />_g <br />DISTANCE TO NEAREST WELL_/5L % ft <br />FOUNDATION ft PROPERTY LINE %GU /- 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 fooTITLE <br />�,.s���st��..c DATE 3/�ZZ. <br />DEPARTMENT U EumpSoil <br />r_• <br />Application Accepted By — 1�1.� Date 3� .�Area H qq Employee ID# rf�✓Ik G <br />Final Inspection By Date ❑ SPECIAL PERMIT - Approved by <br />TT <br />Character of Soil to Depth of V Ft: Pit/Character: <br />COMMENTS ND,1-+arwv, 01, J fe:6c," nte. <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Chec <br />Cash <br />Amount <br />Remitted <br />Dat <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />a) a <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />