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t <br />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 <br />JOB ADDRESS V6 S <br />CROSSSTREET lib <br />OWNER NAME !� 64 (0kl 3 <br />GALL <br />YDJ-10.91 FOR 1NS1'tc;11UNJ GAt'IKtJ I Ii CHK rmum LJ/11 C IJJUCI <br />Q <br />CITY/ZIP / /61 <br />_ APN (1 UOf (� P//A�,RCELSIZE <br />PHONE Wil/ �bi� Imo/ <br />OWNER ADDRESS SI"—'l ` CITY/STATE/ZIP <br />CONTRACTOR �ZVI:�,H4E O itVWU411 I %��� PHONE -1 61 ��,i /te/-(h% �/7( <br />CONTRACTOR ADDRESS �l/ r 7�t7 CITY/STATE/ZIP ✓-11 e G/'-]rl/�ol/ <br />i <br />LICENSE 1-0-42 F1 C-36 OTHER NUMBER 2<2 22 EXPIRATION DATE /+G <br />WATER TABLE DEPTH: i I " ft GEOGRAPHICAL INFORMATION: Coordinates X Y ft <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # N <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED IAL , <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION VFX <br />LINSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL per IP4"' ❑ OTHER ((����� <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: L v;,e W of NUMBER OF EMPLOYEES tiY <br />Zww- <br />�.' <br />❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPART RONM �r <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES LEACHING CHAMBERS # OF LINES_ LENGTH OF LINES y D ft <br />l <br />DISTANCE TO NEAREST WELL ft FOUNDATION � /% ft PROPERTY LINE { ft <br />E3 FILTER BED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION 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 />/SEEPAGE PITS NUMBER_2 WIDTH 3 1 ft DEPTH Z S/ ft <br />DISTANCE TO NEAREST WELL_,S ft FOUNDATION ./0 / ft PROPERTY LINE C� 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 />MIN M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-769c7' _ <br />SIGNED / <br />TITLE GL/� DATE �L - z 7/ z <br />I DEPARTMENT USE ONLY r' <br />Application Accepted By �r�z cc C� Date a Area `I Employee ID# / r <br />Final Inspection By .545 l�� Date 3 Z ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to De th of 3 FY- Pit/Sump Soil Character: <br />COMMENTS Unde VY011'Peo� Tier <br />PE <br />Code <br />SC <br />INFO <br />Received <br />Bv <br />C <br />Cash <br />Amount <br />Remitted <br />Dae <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />