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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-KEFUNDABLE PERMIT <br />(:ALL (LUY) Y03-IOVI FOR INSPECTIONS tXPIRES 'I YEAR FROM DATE ISSUEI <br />JOB ADDRESS <br />4. R11717 <br />7-0,--n-t- c&rz- <br />&2AGr CITY/ZIP-7-CyO (V�— <br />CROSS STREET ( <br />4"14— <br />����Ql <br />/Y7 API atQa 3 PARCEL SIZE 3, I <br />OWNER NAME <br />Lo <br />LENGTH OF LINES yO ft <br />nobs <br />LV k? ci 1`o PHONE <br />OWNER ADDRESS <br />Gj <br />ft <br />CITY/STATE/ZIP <br />CONTRACTOR <br />4'ri <br />Vif, <br />�j� _ ✓? <br />c- PHONE v- Cel -0�) Z <br />CONTRACTOR ADDRESS <br />3741({ <br />7'nf�TL%iI <br />l <br />,�(� CITY/STATE/ZIP <br />�/-�7r�YI� �Jl -7376)1LICENSE <br />❑�-42 <br />OCC -36 <br />OTHER <br />r o� <br />NUMBER �S/UyS EXPIRATION DATE / -3 1 - ,;)I <br />WATER TABLE DEPTH: 6a - 7 ft GEOGRAPHICAL INFORMATION: <br />❑ PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: U NEW INSTALLATION REPAIR/ADC <br />Coordinates X <br />LAND USE APPLICATION #_ <br />)N ❑ ENGINEER DE: <br />❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />Y <br />ED /ALTERNATIVE <br />INSTALLATION WILL SERVE: X 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 7 /4 <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />ft <br />CAPACITY gal # OF COMPARTMENTS <br />CAPACITY gal # OF COMPARTMENTS <br />FOUNDATION ft PROPERTY LINE ft <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />XLEACH <br />LINES <br />❑ LEACHING CHAMBERS <br />9d1 <br /># OF LINES <br />LENGTH OF LINES yO ft <br />oo <br />1 <br />DISTANCE TO NEAREST WELL �S�/ <br />ft <br />FOUNDATION L��) ! ft PROPERTY LINE SG' ft <br />❑ <br />FILTER BED <br />WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />SEEPAGE PITS <br />NUMBER IP WIDTH So <br />ft <br />DEPTH a5' ft <br />DISTANCE TO NEAREST WELL_ <br />ft <br />FOUNDATION /60 r <br />ft PROPERTY LINE SO 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 />DEPARTMENT USE ONLY to <br />Application Accepted B — Date I I 08 a Area —I l Employee ID#EdZ_ <br />Final Inspection By Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS lilies 4,. ��yin� �A��InG ��i5{Pivl <br />PE <br />Code <br />SC <br />INFO <br />Received Check#/ <br />By C s <br />Amount <br />emitted <br />a <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />9d1 <br />1,4 <br />oo <br />1 <br />S D <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />T <br />