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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 PERMITr( L;ALL ZUY Y03--IbYl FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS `Ci ISL) CITY/ZIPj �• M 1C.ti.Qf�/� I" (-'Rxf'a' <br />CROSS STREET AU s�>r r APN o! O O L) �� / PARCEL SIZE lI ! d - <br />I l <br />OWNER NAME Laurel f o . Melyl n Ave PHONE Q <br />OWNER ADDRESS �a q-3 N' ni p)e ll,.� J CITY/STATE/ZIP /�/C� r1 �LG / �_S � <br />CONTRACTOR Y Y I ( 1 r:�IL �� /�_ r PHONE �^ <br />CONTRACTOR ADDRESS pl��x (� CITY/STATE/ZIP /�/'A� P4 f -t G.¢ I C I- (� � <br />LICENSE ❑ 1 C-42 ❑ C-36 OTHER NUMBER EXPIRATION DATE e46 ,_4 / <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION <br />❑ PERC TEST # BUILDING PERMIT # <br />r <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADI <br />Coordinates X Y <br />LAND USE APPLICATION # <br />IN I ENGINEER DESIGNED <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM ! DESTRUCTION <br />INSTALLATION WILL SERVE: V11kESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: l NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY <br />CAPACITY <br />DISTANCE TO NEAREST: WELL ft FOUNDATION _ <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />TERNATIVE <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br />Received <br />By <br />Check <br /># OF LINES <br />Date <br />LENGTH OF LINES ft <br />Invoice # <br />DISTANCE TO NEAREST WELL <br />14�10 <br />ft <br />FOUNDATION <br />14 <br />ft PROPERTY LINE ft <br />/FILTER BED <br />WIDTH ft <br />LENGTH a <br />-w <br />1 <br />ft <br />DEPTH <br />DISTANCE TO NEAREST WELL <br />r <br />ft <br />FOUNDATION <br />10 <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />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 />IV111WIVIVIVI YV 17VVR MU VM/YVL IVV I IVC RL VITAL✓ I VIl /111Jr LV I IV/rJ - !-LL/'7JL V/4LL IGV: <br />SIGNED TITLE CMC d!:rC7 DATE <br />DEPARTMENT U E ONLY <br />Application Accepted <br />B+�y,, L1Date 6 a Area Employee ID#� <br />Final Inspection By (—, Date l�j'taLy ZAP 7D SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />R ; COMMENTS elozA l% Iekc.l� reelI �ar VC "1rioh GC LAY n_ Nvn rejR4.�r 7�er 1L • Lecich lI eS <br />-lube nL,- do me,-) t'_iAd red., ,J T)C, U W� l.iel'A- (.,�'0 - C.u��� TA.n)lJ' <br />PE <br />Code <br />Sc <br />INFO <br />Received <br />By <br />Check <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />14�10 <br />11,5,it <br />L�L <br />14 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />