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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 />LU.9) y53 -/0y/ FOR INSPECTIONS <br />(;,AJ <br />tXNIKLS "1 T LAK rKUM UAIt ISSUtl <br />JOB ADDRESS <br />SO��SQ <br />-LL <br />G J CITYIZIZIP <br />-4 <br />CROSS STREET _ <br />Kei�'Cii <br />, APN / f 1 <br />PARCEL SIZE o <br />OWNER NAME GrO14i <br />dlr, <br />� p4o) t..Gfl'�'iPA <br />PHONE <br />OWNER ADDRESS <br />d9 3 <br />9(,6-ef Inye CITY/STATE/ZIP 9I <br />polo gSsbb <br />CONTRACTOR <br />f�5 <br />e�t�l�-�� S --L - PHONES <br />e^� <br />CONTRACTOR ADDRESS <br />/JG_ Y�C.� <br />p�/� 6 D l ] CITY/STATE/ZIP enc-)' <br />C-0- <br />LICENSE ❑I'IC-42 <br />❑IIC-36 <br />j <br />OTHER NUMBERt9EXPIRATIONDATE� <br />Z <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # 0110 Sod 011 LAND USE APPLICATION # <br />TYPE OF WORK: - NEW INSTALLATION ❑ REPAIR/ADDITION L ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT I J OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: LL,-Fd`ESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br />w-'s-EPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal <br /># OF COMPARTMENTS Gti <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal <br /># OF COMPARTMENTS <br />FOUNDATION MI ft PROPERTY LINE !OI <br />DISTANCE TO NEAREST: WELL too <br />ft FOUNDATION �O' <br />ft <br />PROPERTY LINE 14 6' ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES Ll LEACHING CHAMBERS <br />DISTANCE TO NEAREST <br />❑ FILTER BED WIDTH <br />DISTANCE TO NEAREST <br />❑ MOUNDED <br />❑ SUMPS <br />WIDTH <br />DISTANCE TO NEAREST <br />WIDTH <br />DISTANCE TO NEAREST <br />❑ DISPOSAL PONDS WIDTH <br />WELL ft <br />ft LENGTH <br />WELL <br />ft LENGTH <br />WELL <br />ft LENGTH <br />WELL <br />ft LENGTH <br /># OF LINES —3 <br />FOUNDATION so, ft <br />ft <br />ft FOUNDATION <br />ft FOUNDATION <br />ft FOUNDATION <br />ft <br />LENGTH OF LINES �� ft <br />PROPERTY LINE Q I ft <br />DEPTH ft <br />PROPERTY LINE ft <br />ft DEPTH ft <br />ft PROPERTY LINE ft <br />ft DEPTH ft <br />ft PROPERTY LINE ft <br />ft DEPTH ft <br />/ <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />I <br />ft <br />W SEEPAGE PITS <br />NUMBER -3 WIDTH `4a t� <br />ft DEPTH aS <br />ft <br />Permit ID# <br />DISTANCE TO NEAREST WELLI -Sb ft <br />FOUNDATION MI ft PROPERTY LINE !OI <br />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 TITLES %i j,4b C -*y (� DATE <br />DEPARTMENT USE ONLY ,I <br />Application Accepted/2— Date o 3l ? a Area T /9 Employee ID# In -5 <br />Final Inspection By (( G0 Date t ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS /Oex, j S FR• -Filer ff <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Check#/ <br />ash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />gR11 <br />11-7 <br />' <br />4 ,/ � , 9,63 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14//14/ ;%�18 Ca �`(--"(� <br />