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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 < GALL 11179 953-7697 FOR INSPECTIONS �"L�EXPIRES 1 YEAR FROM DATE ISSUEI <br />VS <br />1 <br />JOB ADDRESS 1 I Jo�� J �%5��� ''� CITY/ZIP n fe-C <br />LU ` _E33C, <br />CROSS STREET sevwt I i�-� APN a 8� s �a .PARCEL SIZE �` �' 13 <br />p <br />OWNER NAME Q16�1 I (U� PHONE /1160�� �S- �yJQ <br />OWNER ADDRESS ( 1lCy�tl+� L�Cf� CITY/STATE/ZIP Yvv'1`\ f_ ca, /. <br />CONTRACTOR I6 6k -vv i f'cxl I1tiZJ� L� I n( PHONE '-_)_0J U Ct C JL V(0O <br />CONTRACTOR ADDRESS 44 6 S iiwy 0i 7 / CITY/STATE/ZIP S ► UG L kin (A <br />LICENSE ❑ C-42 ❑ C-36 OTHER NUMBER 'Z ` EXPIRATION DATE 1nL/�C <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 'k� DESTRUCTION <br />INSTALLATION WILL SERVE: D 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 />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 />B <br />Check#/ <br />ash <br /># OF LINES <br />Permit/ <br />Date Service Request # <br />DISTANCE TO NEAREST <br />WELL <br />W a a 1 <br />ft <br />FOUNDATION <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />LENGTH OF LINES _ <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 />1 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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED TITLE DATE —1 <br />DEPARTMENTUSE ONLY <br />Application Accepted �� Date c?$ Area C Employee ID# <br />Final Inspection By Dateq. El SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS %voh lePct, r' Ter 7 / <br />i 1615-11 1r S/7 1OIS- / c, SS 06I'AP(7/ Lel PCS/CC <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />ash <br />Amount <br />Remitted <br />Permit/ <br />Date Service Request # <br />Invoice # <br />Permit ID# <br />W a a 1 <br />� �s <br />cs�. <br />$ t � �. <br />•Zg2 � �o�S ZO�i <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />T <br />