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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 -REFUND E PERMIT GA LUy yb:f-/by/ FOR INSPECTIONS tXPIRE5 1 TEAR FROM DATE 155UE <br />JOB ADDRESSa 1 J�^71G t / (CITY/ZIP �' 13 <br />CROSS STREET ' l,� ,j APN % U z PARCEL SIZE c� <br />OWNER NAME C �! 7 �I� ("ln%�i!�U PHONE �L��I�,Y�/J <br />OWNER ADDRESS CITY/STATE/ZIP <br />T� <br />CONTRACTOR f�%%IC%S��I y^�f 0 l ! L tJC_ PHONE <br />CONTRACTOR ADDRESS / `U / / 1v� CITY/STATE/ZIP <br />LICENSE ❑❑C-42 1111C-36 OTHER NUMBER7/57 EXPIRATION DATE L� Zy — _ <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION I fF� REPAIR/ADDITION 11 ENGINEER DESIGNED /ALTERNATIVE <br />W REPLACEMENT leC'Ch �IE'IV' ❑ OUT -OF -SERVICE SEPTIC SYSTEM I I DESTRUCTION <br />INSTALLATION WILL SERVE: P RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />-1 LEACHING CHAMBERS <br /># of LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL <br />ft <br />ft PROPERTY LINE ft <br />® FILTER BED <br />/ <br />WIDTH L� ft LENGTH <br />If/Ly <br />C/ O <br />DEPTH �1/ 2 " Dcw� e c#f <br />DISTANCE To NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE C ft <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />It DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft 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 />MINIMUM <br />HOUR DVANCE NOTICE REQUIRED <br />FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br />SIGNED <br />TITLE ✓ <br />v DATE V/ <br />DEPARTMENT USE ONLY wj_ <br />Application Accepted By Date 141Area Employee ID# <br />V1411.2,? <br />Final Inspection By Date SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS Uodefelm,h�ea, 7)'ey J. E)"'i0 cjel th Cl-rrr bc—d. Ajew /e,,A Fiejc i, beim. <br />n cq reo; 6f _e,l l_% f i C IFPS due 4�, " c7 A -?r O,I reo Gy of l le L le71 D f �- C/wi c 4c r. 6 <br />h6,vl� 6 e e M b'ir T` -o", or hive e-'Q7C,1efer,1 J �';Pl� 7b be c+by�dora <br />PE SC Received <br />Code INFO <br />Cash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Permit ID# <br />Service Request # <br />qa» 715- oil <br />15 - <br />-300B 'ZZ <br />5 S <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />V. <br />r <br />