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1 <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 <br />CALL 209 953-7697 FOR INSPECTIONS <br />1 YEAR FROM DATE ISSUED <br />1PERMIT <br />CAPACITY gal # OF COMPARTMENTS <br />-A/ <br />/ExPPI,R^E'S <br />JOB ADDRESS <br />JE <br />CY� <br />Cy( Il)►U <br />a12 5 <br />DISTANCE TO NEAREST: <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />%'7�J.�J`7I`m_ <br />CROSS STREET ,( JjAf� <br />I /��A� <br />l��f' u! 1A <br />/j� /�Cl/T/�Y/ZIP �7 [p' <br />APN ��`�/ � % L/ � � !� U <br />PARCEL SIZE � <br />OWNER NAME T <br />11) I" C C IrIZA214 <br />LEACHING CHAMBERS <br />- <br />PHONE <br /># OF LINES / LENGTH OF LINES �TI / ft <br />/ \ <br />-�^cm,� <br />OWNER ADDRESS <br />FOUNDATION 101 f ft PROPERTY LINE C O� f ft <br />CITY/STATE/ZIP�C�� <br />VC1 <br />//� , <br />CONTRACTOR l��`A <br />�51�✓%c1 <br />U.lt-t >t�T� <br />L PHONE c9 <br />`l <br />6 q "-' � a J _5 J [� <br />CONTRACTOR ADDRESS <br />1 ? a I o <br />vL CITY/STATE/ZIP( <br />�j�2 <br />006-S2 ed �// ! 15 <br />LICENSE ❑ I C-42 A <br />C-36 OTHER <br />NUMBER v / Qd EXPIRATION DATE d / 1(/ zL2U <br />WATER TABLE DEPTH: (V _ U ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT LAND USE APPLICATION # <br />TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION ENGINEER DESK <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />TERNATIVE <br />❑ <br />SEPTIC TANK <br />TYPE/MFG <br />4j <br />CAPACITY gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />a12 5 <br />DISTANCE TO NEAREST: <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />l!l <br />LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES / LENGTH OF LINES �TI / ft <br />/ \ <br />DISTANCE TO NEAREST <br />WELLr ft <br />FOUNDATION 101 f ft PROPERTY LINE C O� f ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />1 <br />j(J <br />SEEPAGE PITS <br />NUMBER � WIIDD�T-H�j �g <br />ft DEPTH S ft <br />DISTANCE TO NEAREST <br />WELL/ �_j-)_`_�L ft <br />FOUNDATION 'I ft PROPERTY LINE _ _ jd 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 />Ir111T1 v1w1 IIv 1 P1✓v/'1 ivv" 1vv 11\/L lxL v1111_✓ I l/1A Ilra7rl. Le11w1Ya7 - I_LC^0L_ V/YLL Ilev. <br />SIGNED _ TITLE 0li4./lJ DATE <br />Application Accepted B <br />Final Inspection By <br />Character of Soil to Depth of 3 <br />COMMENTSTCG�� <br />tYAK I Mt IV / UJ r= UIVL Y <br />Date Area Employee ID# (/Q! <br />Date z�2Z ❑ SP IAL PERMIT -Approved by <br />Pit/Sump Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Received Check#/ <br />jas <br />Amount <br />Remitted <br />Date Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />a74 <br />a12 5 <br />w <br />42-01 ` ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 11 <br />Y <br />tv <br />d <br />