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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-REFUNDABLE PERMIT <br />GALL (ZU9)953-769/ <br />FOR INSPECTIONS` <br />tXPIRES 'I YEAR FROM UATE 155UE1 <br />JOB ADDRESS 10088 <br />AZ- ST. Rr. <br />9-I F a vrA4 <br />E CITY/ZIP//7 rOC(L'rbl� <br />f si e1lI <br />CROSS STREET ` A L SAm <br />By <br />Remitted <br />APN D8G -G7O - 4-7 <br />PARCEL SIZE 7` 7G <br />,1A <br />iPHONE, <br />OWNER NAME AR11E5r <br />BFAV40 <br />o0AM C,'V <br />DISTANCE TO NEAREST <br />PHONE <br />OWNER ADDRESS l0'19 <br />/V ST AT <br />- f / AR O/" <br />&x IF CITY/STATE/ZIP s roZ11Q 0/J/ f'5 a, 2 <br />t9 <br />CONTRACTOR `7 <br />ft <br />❑ FILTER BED <br />PHONE=4OZ.- <br />/�7 <br />CONTRACTOR ADDRESS <br />D <br />y�pl <br />/ l <br />CITY/STATE/ZIP <br />7G- LOGiC L.4 g 38 r <br />LICENSE ❑[C-42 ❑11C-36 <br />OTHER Acjli NUMBER(!EXPIRATION <br />DATE <br />AO/ZZ- <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: L NEW INSTALLATION [' REPAIR/ADDITION L ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT 1 1 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 <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />ft <br />CAPACITY <br />CAPACITY <br />FOUNDATION <br />❑ PKG TX PLANT <br />❑ <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />ft <br />❑ LEACH LINES <br />LI LEACHING CHAMBERS <br />INFO <br />By <br />Remitted <br /># OF LINES <br />Service Req est # <br />LENGTH OF LINES <br />ft <br />2� <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LI <br />ft <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH C�+/�,.,.-7_�— <br />T• <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LIQ er✓ <br />ft <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />ry <br />DEPTH L 3 7n,, <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ee,��••..//�y <br />ft PROPERTVY_M .'W44 <br />ft <br />❑ DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH _R F�IRpV'N CGU/y _ <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LIN DEPq <br />ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />I HEREBY CERTIFY�J-IAT 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 <br />Application Accepted <br />Final Inspection By_ <br />Character ofS it o D <br />COMMENT1 A <br />3 Ft: <br />la"It" <br />Date <br />Date <br />LJrN 11VOf OL,IlV1YJ - r"LCfiJC (LU: <br />TITLE [i/ �/ L �,/llG/N+EE%� DATE <br />T U S f 0 N -L Y <br />j Area -4,dG Employee ID# <br />❑ SPE AL RMIT - Approved by <br />Pit/Sump Soil Character: <br />PE <br />SC <br />Received <br />Chec Amount <br />Permit/ <br />Code <br />INFO <br />By <br />Remitted <br />ate <br />Service Req est # <br />Invoice # <br />Permit ID# <br />2� <br />a <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />