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4 <br />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 CALL (ZOO) Yb:f-/by/ FOR INSPECTIONS tXPIRES "I YEAR FROM UATE ISSUE] <br />JOB ADDRESS ((j/ Cil (L i C�IT+Y/ZIP j /T�(�/7w'O j �] <br />CROSS STREET A,M1/ 4yt e'�C F� j' q� APN L 0!� 3 Q J / PARCEL SIZE I . / D� <br />OWNER NAME )" awc' dw/ r�1 wl 6") <br />l PHONE <br />Jf ONE C <br />OWNER ADDRESS 19 -G� 1 `/til � P CITY/STATE/ZIP 6" )� !, q J -e-?� <br />CONTRACTOR / /(1L 1 PHONE �G� Die ! — 5-01;?7-�^ <br />CONTRACTOR ADDRESS 7.T� '% /IJP- /�J' CITY/STATE/ZIP ./ice Civ' i (' I 95�I <br />LICENSE ❑KC -42 DDC -36 OTHER NUMBER ? EXPIRATION DATE <br />WATER TABLE DEPTH: ?LCIO ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />.l REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM [..I DESTRUCTION <br />FINSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: ' NUMBER OF BEDROOMS: 1-2 NUMBER OF EMPLOYEES: <br />!4 <br />❑ <br />❑ <br />SEPTIC TANK <br />GREASE TRAP <br />LIFT STATION <br />TYPE/MFG 6,ra k_ Z6 <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL 1,20 ft <br />SIZE TYPE OF PUMP <br />CAPACITY gal # OF COMPARTMENTS <br />CAPACITY gal # OF COMPARTMENTS <br />FOUNDATION (d / ft PROPERTY LINE CQ0 ` <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />ft <br />Permit/ <br />Service Re u st #- <br />LEACH LINES <br />❑ LEACHING CHAMBERS <br />9,311 <br /># OF LINES LENGTH OF LINES �s , <br />ft <br />DISTANCE TO NEAREST WELL /00 ' <br />ft <br />FOUNDATION (QO L ft PROPERTY LINE /!J <br />ft <br />❑ <br />FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ <br />SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />l <br />SEEPAGE PITS <br />NUMBER C WIDTH <br />' <br />ft DEPTH <br />�G j <br />DISTANCE TO NEAREST WELL / SO <br />ft <br />FOUNDATION 30 ft PROPERTY LINE <br />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 />DEPARTMENT LkSa QNLY n <br />Application Accepted By 2— Date d / Area IGS Employee ID# V� <br />Final Inspection By Date �i �— ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth oY 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <ecc>hd Un I f. :71er -'y5leh,7 <br />PE <br />Code <br />SC <br />INFO <br />Received <br />Check#/ Amount <br />Cash Remitted <br />D to <br />Permit/ <br />Service Re u st #- <br />Invoice # <br />Permit ID# <br />9,311 <br />42-01 <br />4/14/18 <br />oo53� o30 <br />T <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />