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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 (ZU9)953-169/ FOR INSPECTIONS tXPIRES 'I YEAR FROM UATE ISSUE. <br />JOB ADDRESS XV 15 VI, Ci C+.aIrq I Q V I CITY/ZIP <br />CROSS STREET cq o -e(' APN �0� LIM 33, PARCEL SIZE 14, <br />OWNER NAME (_ ILLS M) n�r1, L/&C-r- l'S A PHONE �^ <br />OWNER ADDRESS P� 'OO �/J�i� CITY/STATE/ZIP 5' SG`! 4) n <br />CONTRACTOR (I G`S d 4510 2-e— 'gkl PHONE/. <br />(ao9`]n^-A 45(Q -2$(125 c, <br />CONTRACTOR ADDRESS Qo�h CITY/STATE/ZIP y c.^Ce JI �!4 5-�?� <br />LICENSE ❑❑C-42 ❑❑C-36 OTHER 94- NUMBER( EXPIRATION DATE '�/ Ji <br />� ss�c <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT #_ZZIOq O LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />..1 REPLACEMENT 7 OUT -OF -SERVICE SEPTIC SYSTEM Ll DESTRUCTION <br />INSTALLATION WILL SERVE: LYKESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />DISTANCE TO NEAREST: WELL I ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ <br />aXEACH LINES [1 LEACHING CHAMBERS <br />DISTANCE TO NEAREST <br />❑ FILTER BED WIDTH <br />❑ MOUNDED <br />❑ SUMPS <br />WELL ft <br />ft LENGTH <br />CAPACITY I ZZ T gal # OF COMPARTMENTS <br />CAPACITY gal # OF COMPARTMENTS <br />FOUNDATION I /� I ft PROPERTY LINE 2 C ft <br />PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br /># OF LINES -- LENGTH OF LINES1 ft <br />FOUNDATION Lfa' ft PROPERTY LINE ft <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />WIDTH <br />DISTANCE TO NEAREST <br />WIDTH <br />DISTANCE TO NEAREST <br />ft LENGTH <br />ft FOUNDATION <br />ft LENGTH <br />WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />ft DEPTH ft <br />ft PROPERTY LINE ft <br />ft DEPTH ft <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />r <br />SEEPAGE PITS NUMBER .J WIDTH 42),II ft DEPTH as ft <br />In <br />DISTANCE TO NEAREST WELL I �`/yI ft FOUNDATION L n �' ft PROPERTY LINE 7 �� ft <br />I HEREBY CERTIFY THAT 1 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 G 1JfT TITLE 6n- E f I -C A. f DATE <br />T <br />f EE D <br />Eff 22 <br />IN CC UNTY <br />ENVIOMNAL <br />ENT <br />DEPARTMENT USE ONLY <br />Application Accepted By li Date vt d oZ Area 7 Employee ID# <br />Final Inspection B Date\�,\ ElSPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sum�p\Soil Character: <br />COMMENTS /)PVJ S F9 <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Check#/ <br />C sh <br />Amount <br />Remitted <br />ate <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />4 a ►1 <br />11-7 <br />L <br />*; 2- <br />5 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />