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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 />11"1014-KEFUNDABLE PERMIT <br />JOB ADDRESS Y :? 4 - <br />CROSS STREET Grc,, <br />OWNER NAME <br />OWNER ADDRESS 410-1 <br />953-7697 FOR <br />EXPIRES 1 YEAR FROM DATE ISSUEI <br />APN 011'"030' 3D f��PAJI <br />R�cELSulE).!^I�QG(] <br />PHONE i �7�+ J OKN ~;y�: [-1� <br />CONTRACTOR ADDRESS �t,/ i6g6x D/Aso J ^ CITY/STATE/ZIP Lod 1%I£7LlryCA, q � q <br />LICENSE ❑DC -42 ❑❑C-36 OTHER V,ll NUMBER �SM.,1 EXPIRATIONDATE_ (/"I// 0aL1 <br />WATER TABLE DEPTH: 2`D ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK- ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED IALTERNATNE <br />F, REPLACEMENT Il OUT -OF -SERVICE SEPTIC SYSTEM fl DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFTSTATION SIZE TYPE OF PUMP Cl PKGTXPLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES <br />Amount <br />LENGTH OF LINES ft <br />Code <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />Invoice # Permit ID# <br />Service Request # <br />ft PROPERTY LINE F <br />❑ FILTER BED <br />WIDTH <br />I ft LENGTH <br />If <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE__�.r,,€t!! <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH R <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE SAA/_ft <br />❑ SUMPS <br />WIDTH <br />It LENGTH <br />ft <br />DEPTH — EA11 <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTYLINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft 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 />SIGNED <br />DATE <br />Character of Soil to Depth of 3 Ft: PittSump Soil Character: <br />COMMENTS <br />e NFry/a <br />1620 <br />IU/N C <br />NryENTU22 <br />�y�-�, <br />;;p' <br />!44/ ?.- <br />PE <br />/ <br />PE <br />SC Received <br />Chec <br />Amount <br />Permit/ <br />Code <br />INFO B <br />s <br />Date <br />Remitted <br />Invoice # Permit ID# <br />Service Request # <br />22 <br />523 <br />/S� <br />/St'op4z&5 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />