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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 (:ALL <br />JOB ADDRESS) � 4�L+�, L <br />CROSS STREET peC) n (;t 4 YJ P <br />OWNER NAME c,,) ) l Sy /P . Aue I eye <br />Y53-IUYI FOR INSPECTIONS tXPIRES 'I YEAR FROM UATE ISSUEI <br />CITY/ZIP I✓ S G G (� h 5 Sd U <br />{� A'PjN/� J� Di D EC)a% PARCEL SIZE <br />PHONE <br />OWNER ADDRESS Sci, j' E CITY/STATE/ZIPtJ ` <br />CONTRACTOR 1 I%.t�� tea, .,e-- PHONE tist, <br />CONTRACTOR ADDRESS l�U C( CITY/STATE/ZIP V� LG4�,4.G,* iG l 3-3,j <br />LICENSE 110C-42 110C-36 OTHER_1144- j n4j EXPIRATIONDATE <br />WATER TABLE DEPTH: s 17'x/ ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # F BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: R <br />ESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: y NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG 101+ L <br />CAPACITY. <br />gal gal <br />#OF COMPARTMENTS_ <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal <br /># OF COMPARTMENTS <br />WIDTH <br />DISTANCE TO NEAREST: WELL I(f�1 <br />ft FOUNDATION 40 <br />ft <br />PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL <br />SEPARATOR (ENCLOSED SYSTEM) <br />B- LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES I <br />LENGTH OF LINES kO� ft <br />5(2 <br />DISTANCE TO NEAREST <br />WELL (Qd tt- ft <br />FOUNDATION 6_ft <br />PROPERTY LINE (' t ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />SUMPS <br />WIDTH <br />ft LENGTH I <br />ft <br />DEPTH 18 ft <br />DISTANCE TO NEAREST <br />WELL f Sd J" ft <br />FOUNDATION [d <br />It PROPERTY LINE % Oar ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />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 />Un 11YJrCI. IIV/YJ - rLG/iJC liliLL FZVVI <br />TITLE Ir DATE 3' <br />i DEPARTMENT U E ONLY <br />Application Accepted By Date y Area Employee ID#_ <br />Final Inspection By Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Dep of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS V �1CAF�C'rM)YlPf- h"YIPS -k TeMC/ lr monde R2 <br />'WC SrDbL M11IC SIUI,72 7q2- <br />�S— C* At� Eo - LoP�9 ��L <br />PE <br />Code <br />SC eceived Chec Amount Date Permit/ Invoice # <br />INFO s Remitted Service Request # <br />Permit ID# <br />5(2 <br />42-01 <br />4/14/18 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />