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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 />(:ALLLU,9 <br />Received <br />B <br />ybJ-/DY/ FOR INSPECTIONS <br />tXPIRES "I FROM DATE ISSUE <br />JOBADDRESS11J I <br />_ <br />❑ FILTER BED <br />WIDTH <br />CITY/ZIP N/1%\✓l�(t:l <br />CT.�EAR <br />1'T33 <br />CROSS STREET <br />k5e"" �(( <br />Ipp��C_ <br />❑ MOUNDED <br />APN ad 3�s O°� <br />PARCEL SIZE <br />LENGTH <br />OWNER NAME <br />CD r�ci I l�L <br />I <br />❑ SUMPS <br />PHONE G i cp - K31- <br />3 Gla 1 <br />OWNER ADDRESS <br />1 <br />A' <br />�V'>ti n <br />T �1 <br />CITY/STATE/ZIP N\C. to Cil, - CA <br />`A 133c- <br />CONTRACTOR <br />Eewi rU^V\/-tAk-t <br />LENGTH <br />PHONE "I <br />73c� G(�UCp <br />WELL <br />CONTRACTOR ADDRESS <br />44-D6 <br />S �-K j \/ <br />-O <br />I r,— F jX 1- CITY/STATE/ZIP <br />S 1DC k- (LV-\ Cil <br />'� -r3LIJ <br />LICENSE [11 C-42 <br />❑ C-36 OTHER <br />C, <br />NUMBER4 -" EXPIRATION DATE <br />10 /d,& <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION trx n I� <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: 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 />❑ LEACH LINES <br />LEACHING CHAMBERS <br />Received <br />B <br />Check#/ <br />Cash <br />DISTANCE TO NEAREST <br />WELL <br />Permit/ <br />Service Request # <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH_ <br />DISTANCE TO NEAREST <br />WELL <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br /># OF LINES LENGTH OF LINES <br />ft FOUNDATION <br />ft <br />ft FOUNDATION <br />ft FOUNDATION <br />ft FOUNDATION <br />ft FOUNDATION <br />ft FOUNDATION <br />ft <br />ft <br />ft <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <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 />MINIMUM48 UOURA VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />f)'1.1\ SIGNED TITLE DATE LI/ 1-•�-I-� a <br />J DEPARTMENT US ONLY <br />Application Accepted B 1—� `L Date Area Employee ID#�� <br />Final Inspection By Date -Zi ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS No:" -fepoor - T)er <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />42 -01 <br />42-01 lS ' ' ^ L ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />VA - <br />