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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> ` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA95205.(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> *25cfqq S.JOB ADDRESS �✓ • CITYIZIP -3 <br /> AA nJ f�'� m <br /> CROSS STREET 7_L Jdw N.f• _, APN • - �1 7 PARCEL SIZE o• 4 9 p <br /> OWNER NAME_. ��� / ha�� PHONE <br /> OWNER ADDRESS 664 J,a�` _ C•� Crry/STATE21P � �/f y <br /> CONTRACTOR �eAPC <br /> AZ /HONE o / — 3re �5�7 4 <br /> CONTRACTOR ADDRESS 1•�• if�� CnTY/STATEIZIP <br /> LICENSE C-42 C36 OTHER NUMBER 4J•-�rEXPIRATION DATE <br /> WATER TABLE``DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION :: 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: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG &ftcA�(- YTfaT7el#1 CAPACITv v gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG ✓ CAPACITY gal #OF COMPARTMENTS_ <br /> DISTANCE TO NEAREST: WELL/ ft FOUNDATION�� it PROPERTY LINE a$ it <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES 1 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ��•7 ft <br /> DISTANCE TO NEAREST WELL • it FOUNDATION o14D , it PROPERTY LINE ? ' it <br /> ❑ FILTER BED WIDTH it LENGTH ft DEPTH it <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> ❑ SUMPS WIDTH it LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTYLINE it <br /> ❑ DISPOSAL PONDS WIDTH it LENGTH ft DEPTH It <br /> DISTANCE TO NEA ST WELL it FOUNDATION ft PROPERTY LINE_ _ft <br /> SEEPAGE PITS NUMBER E WIDTH It ft DEPTH 016-0 _ft <br /> DISTANCE TO NEAREST WELL aMN ft FOUNDATION it PROPERTY LINE _� it <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 /> MINIMUM 48 UOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE A,(-1,7— OZ4 <br /> "40 <br /> 17 <br /> i 2106' <br /> T <br /> EP TMEN SE NLY w— r=mployee <br /> Application Accepted Date Area _ ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of So��Z. iUSu p Soil Character: <br /> COMMENTS I® <br /> 7-1 Loam•C o <br /> ff Z 57oti 1we - <br /> PE SC Received Check#I Amount Permit <br /> de INFO ash ReA ted Date Service Request# Invoice# Permit I�1,f, <br /> &-M ly <br /> 4 ONSITE WASTEWATER TRTMNT SYSTEM PEF <br /> 4114//14I18 <br /> �W) Uploaded into Accela �F��- <br />