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*s I. <br />+ ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-5420 <br />NON-REFUNDABLE PEyRMITi <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUE] <br />JOB ADDRESS <br />�1 <br />�` ✓f1 <br />�� <br />��� CIITYIZIP <br />TYPE OF WORK: <br />CROSS STREET <br />//�X�Ji <br />yLl / /�O�J� <br />/ ` <br />�I (✓ E APN �L' v`! L J <br />I <br />PARCEL SIZE _ <br />OWNER NAME/�/� <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />PHON1E'�L`CMn <br />I COMMERC l;)W OTHER <br />%� ///�•-Q1() <br />C <br />OWNER ADDRESS <br />Z () <br />1 ��r� CRYISTATE/ZIP lid- <br />fur <br />CONTRACTOR <br />dti1j4TP" <br />raux Sc�PHONES <br />3L V1 <br />CONTRACTOR ADDRESS U <br />� -(,/ ��I W l'e C rY1STATFJLP <br />LICENSE A C-42 <br />C-36 OTHER <br />NUMBER EXPIRATION DATE <br />(, <br />�i L5 <br />WATER TABLE DEPTH: <br />It GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />PERC TEST # <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEW INSTALLATION <br />REPAIR/ADDITION <br />ENGINEER DESIGNED /ALTERNATIVE <br />❑ <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE <br />I COMMERC l;)W OTHER <br />�Qejd <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: i <br />}K I NUMBER OF EMPLOYEES: <br />1� <br />Z () <br />' <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 />SUMPS <br />y <br />ft <br />DEPTH I C ft <br />DISTANCE TO NEAREST: WELL '- <br />ft FOUNDATION J <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />O PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />A <br />LEACH LINES <br />LEACHING CHAMBERS 7 *GF LINE_ <br />LENGTH OF LINES 7) ft <br />DISTANCE TO NEAREST WELL C� R FOUNDATION <br />j� <br />v <br />ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL It FOUNDATION <br />It PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />It <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />SUMPS <br />WIDTH Z R LEN�GT�H�� 2 U <br />ft <br />DEPTH I C ft <br />DISTANCE TO NEAREST WELL 1V7v ft FOUNDATION l.' <br />_ <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH fl LENGTH <br />it <br />DEPTH ft <br />DISTANCE TO NEAREST WELL It FOUNDATION <br />ft PROPERTY LINE It <br />❑ <br />SEEPAGE PITS <br />NUMBER WIDTH <br />ft <br />DEPTH It <br />DISTANCE To NEAREST WELL ft FOUNDATION <br />It 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 />DEPARTMEN USE ONLY <br />Application Accepted By Y_ Dates r v Area i % Employee ID# <br />Final Inspection By Date h t - I 1 SPECIAL PERMIT - Approved by <br />Character o1 Soil to,.�Dep?M�' of PiUSump Soil Character: <br />COMMENTS Acl-rh }i,n b(-tqo bedroa»K. T P r Z , e' <br />Il'ncs 4o tc!t»,:�,L1i �`�• b'�� t L -I. 71 439�- <br />PE SC Received Ch Amount Date Permit! Invoice # Permit ID# <br />Code INFO Remitted Service Request # <br />aio Is 2 3�a <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />