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v1. 09 r L- •vr%.J I GvvM I CR I P[CH I IVIMN I sT,I tM F I=KMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ' Dp,,r W• W aR')DGS -CITY/Zip C-01>I q S-2-`+2- <br /> CROSS STREET Yr`Vyy, S ! y� APN 01 04 J-(� PARCEL SIZES D'CIE uF <br /> o <br /> OWNER NAME J�\rnli� IT�Li\F�fV PHONE J6�Qc) <br /> OWNER ADDRESS SSG CITY/STATE21P I� <br /> CONTRACTOR I-1 f QPg4 6rI-Cf-NV II�2oN M E A!%A L_ PHONE_.3O' 1q <br /> - 01 � C. <br /> CONTRACTOR ADDRESS 40-1 W. e) Ie- S7• CITY/STATE/LP L-C-C>I C'A /S�1--+0 <br /> LICENSE QC-42 QC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: C NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED IALTERNATNE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS:.. NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <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 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ 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 /> W <br /> DISTANCE TO NEAREST ELL 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 WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 /> INIMUMR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE CQN S IL 11 1T1V T DATE <br /> n <br /> W eeQc / )iQ El ii <br /> HENT <br /> ii9CEIVED <br /> _ - - ,� <br /> to <br /> M1 <br /> L---- \,\ ' Ile <br /> 0 3 2019 <br /> ^' ` AQUIN COUNTY <br /> ENVIRONMENTAL <br /> DEPARTMENT <br /> 1 771 <br /> DEPARTMENT USg ONLY <br /> Application Accepted By Date 71 Area ��Employee ID# Si"J j- <br /> - <br /> Final Inspection By Date ❑ SPE L PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character. <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/Code INFO Cash Remitted Date Service Request# Invoice# Permit ID# <br /> 42-0„' ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />