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1 <br />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 <br />/PERMIT �1 CALLS /209 953-7697 FOR INSPECTIONS { / . EXPIRES 1 YEAR FROM <br />FROM DATE ISSUED <br />JOB ADDRESS TJ �D e . LAI -k lqr' a IV l CITYIZIP 1 11'11V 1 1rA f '� ---�-' /; <br />CROSSSTREET �%]�L),T7 �( fj „.t1(,�1 �/.Y[ APN 1:9 � 04 00PARCEL SIZE I/�� - f'6RA- <br />OWNER NAME (11�v:/::CR :\ I1'!11 V f�J 1 `O� �r�.11 PHONE �DC( K/rl�'� I nO <br />OWNER ADDRESS ��J' VTY r Nj d) P-"yr�f�-.+I rleT+ r CITY/STATE/ZIP 1 'q�, v�tIF-LA / i V'T I 3'J{O <br />CONTRACTOR :a M �rGy Q Y/CUC- WQh� 1A 1i e —UT PHONE �O 1 -4 .5 0 — 0 1'10 <br />CONTRACTOR ADDRESS�/ -_� 5 S N . 7' I �1 ✓� C., /,, CITYISTATE/ZIP tJ �j C. 9 <br />LICENSE L C-42 I Q36 OTHER NUMBER.0 ✓ OW EXPIRATION DATEL7%� <br />Application Accepted <br />Final Inspection By <br />Character of Soil to D <br />of 3 <br />Area I / l l Employee ID# <br />Z -L SPECIAL PER—MIT -Approved by <br />Pit/Sump Soil Character: <br />c <br />. Jo <br />V �VRO [/hy CO <br />T yD�p1qR 114 <br />COMMENTS <br />Gea C-4 <br />PE SC Received ec Amount ' Permitt <br />ode INFO B Cash RemittDate Invoice <br />ed eryice Re uest # <br />C # Permit IDN <br />I J <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />WATER TABLE DEPTH: <br />V / ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # <br />BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEW INSTALLATION REPAIRIADDITION ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER <br />NUMBER OF LIVING UNITS:,, I NUMBER)OF BEDROOMS: 2- NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG C 4 CAPACITY 12oc gal #OFCOMPARTMENTS 'L <br />W <br />❑ GREASE TRAP <br />TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE To NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />LEACHING CHAMBERS # OF LINES 5 LENGTH OF LINES aG� ft <br />I�_ 1 <br />DISTANCE TO NEAREST WELL �� ft FOUNDATION :Jft PROPERTY LINE (U V ft <br />❑ FILTER BED <br />WIDTH ft LENGTH ft DEPTH It <br />DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH It LENGTH It DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION 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 ES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MI IMUM <br />H U V N E N`� I E Q IRED FORE PECTIONS CALL (209)953 7697�j�'� <br />SIGNED <br />(NSf -PLEASE <br />% iJl DATE <br />Application Accepted <br />Final Inspection By <br />Character of Soil to D <br />of 3 <br />Area I / l l Employee ID# <br />Z -L SPECIAL PER—MIT -Approved by <br />Pit/Sump Soil Character: <br />c <br />. Jo <br />V �VRO [/hy CO <br />T yD�p1qR 114 <br />COMMENTS <br />Gea C-4 <br />PE SC Received ec Amount ' Permitt <br />ode INFO B Cash RemittDate Invoice <br />ed eryice Re uest # <br />C # Permit IDN <br />I J <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />