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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ` I/ - <br /> —CITY/`ZIP y <br /> CROSS STREET APN VO 7r �` PARCEL SIZE i'17 <br /> OWNER NAME R-11614o, EnvikS PHONE�y[_/% <br /> OWNER ADDRESS q q V)/�'I �f, - CITY/STATE/ZIP -IuC'CTul1� �5�1� y <br /> CONTRACTOR PHONE `�"��� <br /> CONTRACTOR ADDRESS +�/'/�/zz7 CITY/STATE/Zip� �/�// <br /> LICENSE ❑LIC-42 ❑UC-36 — <br /> OTHER NUMBERza ue EXPIRATION DATE <br /> co " � <br /> WATER TABLE DEPTH: S D'�� bo ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: C NEW INSTALLATION REPAIR/ADDITION 0 ENGINEER DESIGNED/ALTERNATJJVE <br /> A REPLACEMENT IGIY1 k FI OUT-OF-SERVICE SEPTIC SYSTEM X DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL.t ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: J NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG t/1'�2 �Z CAPACITY ����U gal #OF COMPARTMENTS c� <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> i <br /> DISTANCE TO NEAREST: WELL—'e5) ft FOUNDATION ft PROPERTY LINE 'z_/2 ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> EACH LINES ❑ LEACHING CHAMBERS #OF LINES _ LENGTH OF LINES � 2 ft <br /> DISTANCE TO NEAREST WEL. -D_ ft FOUNDATIONv ft PROPERTY LINED ft <br /> LlFILTER BED WIDTH ft 'LENGTH 1(; 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 N4AREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ZL SUMPS WIDTH lT ft LENGTH I )� 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 /> 'zEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> f 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 /> M 48 HOUR ADVAN NOTICE REQUIRED FOR INSPECTIONS4zPLEASE CALL 209 953-7697 <br /> SIGNED % - TIT DATE <br /> 1 0 0 N <br /> DEPARTMENT USE ONLY �s �} <br /> Application Accepted �r 1� Da._ IF /ST ad Ov70 Area l 7 Employee ID# _ <br /> Final Inspection By ' Date 262 ,! ( SPECIAL PERMIT-Approved by <br /> (4 ) <br /> Character of Soil to Depth of 3 Ftl Pit/Sump Soil Character: <br /> COMMENTS 955S6 rov+ W}ruStlbh. x kts' or ex! 7 Nr &LIon S,0006,20q f <br /> ai bpToVt'd loV C 15' 46-W lead bit �n 11.1.0, I'✓ x l � �� L 1� �' u <br /> 2 61,51' Z262'I turn - a� 41 19 road I j-e" 1 <br /> PE SC Received heck# Amount Permit/ <br /> Code INFO By as Remitted Date Service Request# Invoice# Permit ID# <br /> Baia 1�5" 22. 300 V5- 10s�nuz at <br /> 42-01 v - L,#,*, D r n ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />