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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STocKTGN CA 95205 -(209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS <br />JOB ADDRESS 213C, n v 5 Ra CITY/ZIP et-.1 vl <br />APN '-aq7 01 5-- (-) -3. 2-- PARCEL SIZE ker <br />PHONE —6.(4 q6C5-4/ 6C-1 <br /> <br />Scc, otA <br /> <br />1)4A) <A<-- <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS GC, IS":1 144 c- .1 .5 4-, I <br />CONTRACTOR CAA) '110- <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />CITY/STATE/ZIP <br />PHONE <br />LICENSE El C-42 E C-36 OTHER NUMBER EXPIRATION DATE <br />LAND USE APPLICATION # BUILDING PERMIT # PERC TEST # <br />is) Po eceiv <br />WATER TABLE DEPTH: D (;) GEOGRAPHICAL INFORMATION: Coordinates X <br />TYPE OF WORK: NEW INSTALLATION <br />REPLACEMENT tC:0 1,- 4 I r <br />REPAIR/ADDiTioN <br />OUT-OF-SERVICE SEPTIC SYSTEM <br />I I ENGINEER DESIGNED /ALTERNATIVE <br />)0 DESTRUCTION te,i k <br /> <br />INSTALLATION WILL SERVE: A RESIDENCE E COMMERCIAL <br /> <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />E OTHER <br />NUMBER OF EMPLOYEES: <br />13 <br />0 <br />SEPTIC TANK TYPE/MFG ?ti L Ccrylc CAPACITY gal # OF COMPARTMENTS c- <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 0 PKG TX PLANT 0 SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />U LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />0 FILTER BED WIDTH ft LENGTH LW ft DEPTH q 2 <br />, <br />ft <br />DISTANCE TO NEAREST WELL <5'n° ft FOUNDATION ft PROPERTY LINE ii; ft <br />CI MOUNDED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />0 SUMPS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />0 DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />0 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 />MINIMUA&48IQUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE (71,‘ AP 1— DATE 6-27/VZ <br />CA <br />SIGNED <br />,co <br />VIROA/M COOA, Ty <br />D &-84, 774fr <br />CAN <br />DEPARTMENT ysE ONLY <br />C, <br /> <br />Date Pi) I Area ii1161(-2 <br /> <br />Date tS \ E SPECIAL PERMIT-Approved by <br />Pit/Sump Soil Character: <br />COMMENTS Re1oceil4nj sy 's-t-em for expt--,Aior 6 de ;la-, 6'O Artrzi <br />(An <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By ,.sh <br />CiC4e,acyfil Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Permit ID# <br />1-13 10 i 1 C MA* (.,g -3°C) 0 (:t(2-1 \q-,DDIC3351? <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 42-01 <br />4/14/18 <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />Application Accepted By <br />Final Inspection By <br />Employee ID# <br />Character of Soil to Depth of 3 Ft: <br />Lo t•-) :SS31:1013V 311S