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0 <br />0 <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 PERMIT <br />L;ALL LVJ FOR INSPECTIONS CXPIK^ES "I TEAK 1-KUM UAI t ISSUL <br />,J/OS-/OJ/ <br />.N NF (� // �"t- <br />JOB ADDRESS 122 <br />CROSS STREET <br />I 1pf'ktC/. <br />APN_ <br />-CITY(//ZIP <br />DLI q d, I o PARCEL SIZE <br />OWNER NAME <br />/! <br />/aa- I C if Ile i <br />� Sw-- T""/ <br />PHONE <br />OWNER ADDRESS <br />CONTRACTOR <br />ef J1) <br />I �/IG'1 f <br />V�l <br />CITY/STATE/ZIP '1 .? �i say off/ <br />PHONE �d J� `�_ 2d / <br />/'C`y�m, <br />�A <br />V "u I �/�� 4 "/ c�/9/t <br />nl <br />CONTRACTOR ADDRESS 3/ /T6, %�'WIL1 <br />LICENSE [IXC' -42 ❑1.0-36 OTHER <br />C <br />-' K �r CITY/STATE/ZIP 'S) C //-r r, <br />NUMBER O EXPIRATION DATE q13-0 <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ <br />PERC TEST # BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION / ❑ <br />REPAIR/ADDITION L ENGINEER DESIGNED/)ALTERNATIVE <br />Permit ID# <br />REPLACEMENT 'rG,►�I< t 1 6��J 11 <br />OUT -0F -SERVICE SEPTIC SYSTEM DESTRUCTION All <br />INSTALLATION <br />WILL SERVE: <br />❑ COMMERCIAL ❑ OTHER <br />/RESIDENCE <br />NUMBER OF LIVING UNITS: ` NUYBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG ICY J! / 7 <br />CAPACITY �� gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />/ / <br />ft FOUNDATION CPO ft PROPERTY LINE �OO ft <br />❑ <br />LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />X <br />LEACH LINES i-1 LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES �P ft <br />DISTANCE TO NEAREST WELL /00 ` <br />nC? <br />ft FOUNDATION 120 / ft PROPERTY LINE a� ft <br />❑ <br />FILTER BED WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />MOUNDED WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SUMPS 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 ft FOUNDATION ft PROPERTY LINE ft <br />SEEPAGE PITS NUMBER WIDTH LIP /1 ft DEPTH o�� I ft <br />DISTANCE TO NEAREST WELL / I <br />ft FOUNDATION BG r ft PROPERTY LINE „?O 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 209 953-77697 <br />SIGNED <br />/ <br />TITLE el0 6(//0— DATE �— l �� dc;2 <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Depth <br />COMMENTS 0,11k V <br />o v4 r 1 <br />DEPARTMENTUS ONLY <br />Date Q Area Employee]D# Fry n k <br />Date 11Z-3 t -z ❑ SPECIAL PERMIT - Approved by <br />Pit/Sump Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Received Check#/ Amount <br />Cash Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />�lalo <br />Is" <br />''�f � �31a <br />• 8•ZZ <br />S <br />CZ <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />