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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 /7020 WF66T Von/ SofTE.t/ <br />CITY/ZIP 7-/2.4,-V <br />95�0� <br />ft <br />CROSS STREET e4R1Ck14V <br />APN -D OZ <br />PARCEL SIZE <br />❑ <br />OWNER NAME fl:sus d f1DfLA AlERNA-Nn <br />Fz <br />PHONE .5-1 o -G (7' <br />4D4 <br />OWNER ADDRESS 170Z-0 <br />Vaj� 3oSTEd <br />CITY/STATE/ZIP T�GI/ <br />, [' A SjO- <br />4- <br />r <br />CONTRACTOR r ySNL� QMSUL:? AIJ6 <br />PHONE <br />�fq <br />ft <br />CONTRACTOR ADDRESS . O GES K 3:79 <br />CIN/STATE/ZIP <br />( (ZL'%L iC. CA <br />95"3431 <br />LICENSE ❑LSC -42 ❑❑C-36 OTHER AL41 <br />NUMBER 5-77 EXPIRATION DATE <br />(O /3 O L'2- <br />ft <br />JATER <br />TABLE DEPTH: Z% ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION 1 REPAIR/ADDITION ❑ ENGINEER DESIGNED (ALTERNATIVE <br />Fj REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ <br />❑ <br />❑ <br />SEPTIC TANK <br />GREASE TRAP <br />LIFT STATION <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />ft <br />CAPACITY <br />CAPACITY <br />FOUNDATION <br />❑ PKG TX PLANT <br />❑ <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />❑ LEACHING CHAMBERS <br />5a3 <br /># OF LINES <br />-f►sa <br />LENGTH OF LINES ft <br />5R 00 2 <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />I HEREBY CERTIFY j,Fi14T I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />/t <br />/) STATE LAWS AND RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY. <br />SIGNED <br />V![ IIYJrC/I/r 1IWIVO /- rLCHJC 1..MLL I LV7 <br />TITLE /NLC,6;IZ DATE <br />DEPARTMENT U E ONLY <br />Application Accepted By 1-� �� Date I 1 /a /,71 Area S �'/ % Employee ID# k <br />Final Inspection By Date 'e"Oe.1 ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS '*I- Rr14 <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />Naaa <br />5a3 <br />; <br />-f►sa <br />11-2--7-1 <br />5R 00 2 <br />42-01 z332/ ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />