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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 PERMIT <br />JOB ADDRESS l [Z7 3 S ' D -e— V S <br />CROSS STREET <br />OWNER NAME - p00 L4 N4 <br />4 <br />OWNER ADDRESS A Wnnr <br />11 <br />GALL (ZUy) 9 10Y FOR INSPECTIONS LXPIRES "I YEAR FROM UATE ISSUE <br />CITY/ZIP [_'/G4 // && / <br />APN D) _� QL' Q I O PARCEL SIZE h <br />PHONE <br />TATE/ZIP <br />CONTRACTOR C_2M /7 �j C/`J / PHONE �© 26� �/ 70d / Q a <br />CONTRACTOR ADDRESS / l C "`����� �1�C� /9 - CITY/STATE/ZIP <br />LICENSE ❑pfC-42 ❑C;C-36 OTHER NUMBER EXPIRATION DATE �ob <br />WATER TABLE DEPTH: <br />SC <br />INFO <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />Check <br />s <br />❑ <br />PERC TEST # <br />Permit/ <br />Service Request # <br />BUILDINGPERMIT# BF-2oC)ag3L LAND USE APPLICATION# <br />Permit ID# <br />TYPE <br />OF WORK: <br />NEW INSTALLATION <br />❑ REPAIR/ADDITION I- ENGINEER DESIGNED /ALTERNATIVE <br />,faaLj <br />FJO.T2 <br />S d <br />I REPLACEMENT <br />OUT -0F -SERVICE SEPTIC SYSTEM I , DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE <br />❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: <br />NUMBER/OF BEDROOMS: NUMBER OF EMPLOYEES: <br />(� <br />JQ..I <br />SEPTIC TANK <br />TYPE/MFG <br />5 C CAPACITY l —gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: <br />``//►► ``,w <br />WELL 1(:90 r ft FOUNDATION (V ! ft PROPERTY LINE !(e , ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />--a <br />LI LEACHING CHAMBERS # OF LINES LENGTH OF LINES /00 ft <br />DISTANCE TO NEAREST <br />WELL W ft FOUNDATIONt lift PROPERTYLINE ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH <br />ft LENGTH ft DEPTH ft <br />DISTANCE To NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH <br />ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL 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 />SIGNED <br />P__ DATE _ H " /O =�2� <br />T <br />DEPARTMENT USE ONLY <br />Application Accepted Byyy/ Date / Area Employee ID# v <br />Final Inspection By AlAff- Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS 5eco)7d SFR. 1'..Y -11 <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check <br />s <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />Llai i <br />0.7 <br />Z, , <br />,faaLj <br />FJO.T2 <br />S d <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />