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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 HERMIT GALL (ZU,9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE] <br />JOB ADDRESS 800 �%0551%A L E ��' CITY/ZIP I-Arf/AOP <br />CROSS STREET �y19O &PA5 f APN a 3 f - 0 30- O9 PARCEL SIZE <br />J <br />OWNER NAME mp sjyAL, ,L 15.o, ac . 4 -no • PHONEC2,9:1ct S4S- B�oD <br />OWNER ADDRESS 10• � ` L7Ox �� 2 CITY/STATE/ZIP �4AZM/lOP / S3?y <br />CONTRACTOR _7L, `0 A( UL 7-f Al PHONE d7-0? �'y���S <br />- n' -o2 <br />CONTRACTOR ADDRESS P • 0 ,I 6 o x 379 -� CITY/STATE/ZIP �/cs-OL lC, 44 <br />2.53e/ <br />LICENSE' ❑L C-42 El!:C-36 OTHER IZ,G� NUMBER C S EXPIRATION DATE A <br />WA R TABLE DEPTH: 04 0 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: 0 NEW INSTALLATION ❑ REPAIR/ADDITION I_ ENGINEER DESIGNED /ALTERNATIVE <br />I I REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION <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 1_I LEACHING CHAMBERS # OF LINES <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />M <br />LENGTH OF LINES <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />ft <br />FOUNDATION <br />ft PROPERTY u <br />1Y3 <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft . <br />DEPTH 11P , <br />ft <br />ft PROPERTY LIN-oA!�%Ml � <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />ft <br />FOUNDATION <br />DEPTH <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DISTANCE ToNEAREST <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 />O DISPOSAL PONDS <br />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 />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />M <br />LENGTH OF LINES <br />ft <br />ft PROPERTY <br />ri <br />ft <br />rr <br />DEPTH ttCCjVrw <br />ft <br />ft PROPERTY u <br />1Y3 <br />ft <br />DEPTH M22 <br />ft <br />ft PROP II(DA <br />ENVIRON OUN7 <br />ft . <br />DEPTH 11P , <br />ft <br />ft PROPERTY LIN-oA!�%Ml � <br />ft <br />DEPTH <br />ft <br />ft PROPERTY LINE <br />ft <br />DEPTH <br />ft <br />ft PROPERTY LINE <br />ft <br />I HEREBY CERTIFY THY9 AVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />/Q"ATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />IYIIIYIIYI III Y /7VV H IYVC IYV IIIiC RC VIRGL/ I-VIT 11YJI-Cl, I IVIYJ - rLC/-IJC 14V: <br />SIGNED TITLE 114 ✓14- jjg l //fiEGOle— DATE <br />r--�7 Z_' DEPARTMEN USE ONLY <br />Application Accepted BBny -- /��:Z Date �3 _ Area 3 �� Employee ID# <br />Final Inspection By 1"� , ) - - nz Date El SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Qqheck <br />—Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />L,:)3.7 <br />S33 <br />3q <br />-164 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />