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` ► ti 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 <br />LEACH LINES <br />CALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE] <br />JOB ADDRESS �� <br />Amount <br />Remitted <br />I_ <br />A�/ff1J%YY! hiYc�li <br />j <br />CITY/ZIP s/zi �cy✓ <br />CROSS STREET <br />/ <br />Gw <br />APIN O OSa� PARCEL SIZE <br />�j%b1Y/i� <br />OWNER NAME_////i�j7{ <br />ft LENGTH <br />/ <br />%iiJ�LYS� <br />—� / <br />//�+�CJG�7/' PHLONNE� <br />OWNER ADDRESS 20 <br />k]p+X/ <br />74117 <br />CITY/STATE/ZIP s -To F po S �� <br />CONTRACTOR G <br />/1/1�L////��tt/ <br />WIDTH <br />���� PHONE <br />CONTRACTOR ADDRESS ��74aJ�jry//Gt+N <br />�� <br />///i� %�`�yy�--yC CITY/STATE/ZIP <br />LICENSE ❑6.42 <br />❑❑C-36 <br />OTHER <br />NUMBER 7>7��/S EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: <br />❑ PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: 11 NEW INSTALLATION JK REPAIR/ADC <br />Coordinates X <br />LAND USE APPLICATION # <br />)N ❑ ENGINEER DE <br />❑ REPLACEMENT ❑ OUT -0F -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />Y <br />ED /ALTERNATIVE <br />INSTALLATION WILL SERVE: A- RESIDENCE ❑ COMMERCIAL ? El OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: J NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG ,D s�i wt CAPACITY <br />❑ GREASE TRAP TYPE/MFG CAPACITY <br />DISTANCE TO NEAREST: WELL ft FOUNDATION <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT <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 /># OF LINES LENGTH OF LINES ft <br />Amount <br />Remitted <br />Date <br />DISTANCE TO NEAREST <br />WELL 140 <br />ft FOUNDATION a?o ft PROPERTY LINE 5749 �� ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />g <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />SUMPS <br />WIDTH / <br />ft LENGTH �y <br />' ft DEPTH /Q ft <br />DISTANCE TO NEAREST <br />WELL / 51:)",l <br />ft FOUNDATION �l ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />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 />IYI/IYIIY /YI -to "www /iUV/'1IYVG IV I IVG RC VII�G✓ U- WTI IIYJ rGV / IV/YJ - t-LL/"1JL V/'7LL LVJ JJJ-/VJ/ <br />SIGNED oe; TITLE C_ DATEIf -IF <br />DEPARTMENT USE ONLY IJ <br />Application Accepted By Z Z <br />Date Z 2 • Area y Employee ID# FfliF �. <br />Final Inspection By Date 1 ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth 3 Ft: Pit/Sump Soil Character: % <br />COMMENTS Frh; 11'n4 tlr54em l �%� (ptcOg 611 r, �� ��y� - p* N� 1^ -}, <br />Did) r)c•..J �1 vlbt �,U A) beck kf pywe-t7vl <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Check#/ <br />a <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service quest # <br />Invoice # <br />Permit ID# <br />Waco <br />i 1!' <br />g <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />