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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 />&OD - 10-0" sT • ordzi, c4 c2c' <br />CROSS STREET t E7- 10E- APN 71/0 <br />PARCEL SIZE <br />OWNER NAME A-v2tA t-- e <br />PHONE a'n CI 0 5- t5 2—€;. <br />OWNER ADDRESS I (2:APO _ CD-rk" cirdsTATE/z,p <br />CONTRACTOR 0-on <br />PHONE <br />JOB ADDRESS <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE 03C-42 0=C-36 OTHER <br /> <br />NUMBER <br /> <br />EXPIRATION DATE <br />WATER TABLE DEPTH: <br />0 PERC TEST # <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION <br />L REPLACEMENT <br />_ REPAIR/ADDMON L ENGINEER DESIGNED /ALIERVA_TivEL <br />OUT-OF-SERVICE SEPTIC SYSTEM A DESTRUCTION <br /> <br />INSTALLATION WILL SERVE: 0 RESIDENCE <br /> <br />0 COMMERCIAL <br /> <br />OTHER <br /> <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 11 <br />ID LIFT STATION SIZE TYPE OF PUMP 0 PKG TX PLANT 0 SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES C LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE ft <br />FILTER BED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE ft <br />CI MOUNDED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />LI SUMPS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE 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 UNE 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 />SIGNED <br />OUIV kilANCE NOT! REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />. TITLE (--1/V/Ve32-•-. DATE <br />hS <br /> PAYMENT <br />RECEIVED <br />JAN 25 2021 <br />NJOAQU(N COUNTY <br />ENVIRONMENTAL <br />HEAL H DEPARTMENT <br />Area # CI <br />DEPARTMENT USE NLY 11 <- <br />Application Accepted Employee ID# <br /> <br /> Date / ,.?..5 - .2 i <br />Final Inspection By Date -2,4 W 20Z1 0 SPECIAL PERMIT -Approved by <br />Character of Soil to •epth of 3 Ft: Pit/Sump S il Character: <br />COMViENTS . 4 " "t0 • ilail• r i , 1-- ip1 r7z, e 4 1- 7 47er Z07.0 <br /> <br />t- At14- 1//We.- Cr - et <br />PE <br />Code INFO <br />Receive <br />Remitted Date Date Permit/ <br />Service Request # Invoice # Permit ID# <br />(-Pal 07.s- 41s-02 1176-12,1 s00,1346 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />In sfrvs/eK 5 <br />V-01,412