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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-REFUNDABLE <br />GALL <br />ZUy yb3-1bby/ FOR INSPECTIONS�/�/� <br />CXPI`RE5 "1 YEAR I -RUM UA It- 155UEI <br />��PyyErrRMIT <br />JOB ADDRESS il+'�(y <br />c <br />Sit. ff Iva <br />913 CITYIZIP' <br />i ft DEPTH 1 $ `I <br />ft <br />DISTANCE TO NEAREST WELL I4b I ft <br />"' �� 00!j <br />LI <br />CROSS STREET e,crS H1Lr <br />1 <br />APN,� <br />PARCEL SIZE , <br />�� _ <br />k <br />i l l?e�r <br />%2 <br />Z �' <br />❑ SUMPS WIDTH ft LENGTH <br />ft DEPTH <br />OWNER NAME / / I <br />MilleI {C1)i <br />` <br />FOUNDATION ft PROPERTY LINE <br />PHONE <br />j� <br />OWNER ADDRESS Pa 'V OX a <br />03 va <br />CITY/STATE/ZIP C/ <br />,} p, V,-4 ))'Cl <br />CONTRACTOR V1 'UL`! <br />fact <br />-0 L PHONE if Q,+*!j <br />` T&.C- <br />CONTRACTOR ADDRESS P) <br />/1+.� <br />�� �1 V <br />CITY/STATE/ZIP 0 <br />-6-t 7`-[' -1 1 Lil <br />LICENSE ❑LIC -42 1111C-36 OTHER <br />4 <br />NUMBER EXPIRATIONDATE <br />WATER TABLE DEPTH: L] C) d ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK:EW INSTALLATIO ! REPAIR/ADDITION I I ENGINEER DESIGNED /ALTERNATIVE <br />`l'_�REPLACEMENT l C L OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION fl VI k <br />INSTALLATION WILL SERVE: L/--�ESIDENCE ❑ COMMERCIAL❑ OTHER <br />-/NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: ili3 NUMBER OF EMPLOYEES: <br />{I SEPTIC TANK TYPE/MFG }' _ CAPACITY gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL )o ft FOUNDATION AD, ft PROPERTY LINE S ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES _ LEACHING CHAMBERS <br /># of LINES LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />FILTER BED WIDTH )lot t LENGTH .31P <br />i ft DEPTH 1 $ `I <br />ft <br />DISTANCE TO NEAREST WELL I4b I ft <br />FOUNDATION 101 ft PROPERTY LINE �jr <br />ft <br />❑ MOUNDED WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SUMPS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <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 />MINIMUM 48 HOUR DVANCE NOTICE REQUIRED <br />FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED <br />TITLE 6 (_ DATE (at 1 ;0 <br />Final Inspection By Date��AQ LlLU 2Z ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 t• Pit/Sump Soil Character: <br />COMMENTS <br />rt' I <br />�t'e�Ccel�nt sLs}•em �r exR/�hsl�o-'� 6-F rPsic.�f'rnce, Ti Fr .J1- /�,�n ,�/e�1 W,}���n seta/,� ,��onC <br />PE SC <br />Code INFO <br />Received heck Amount Date Permit/ Invoice # <br />BV s Remitted Service Request # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />T <br />