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REPAIR/ADDMON <br />OUT-OF-SERVICE SEPTIC SYSTEM <br />c ENGINEER DESIGNED /ALTERNATIVE <br />C DESTRUCTION <br />.1•• PERC TEST # <br />TYPE OF WORK: 11 NEW INSTALLATION <br />REPLACEMENT <br />BUILDING PERMIT # LAND USE APPUCATION # <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 868 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 ss-130 f-3 • ft 1°F RL cn-yalp cyr3.3-0 <br />CROSS STREET COL L E.r2. APN 001 - 2.-SO - PARCEL SIZE -t• Ar • <br />OWNER NAME j-o rz. cr <br />OWNER ADDRESS S 14% rYN C CRY/STATE/ZIP <br />PHONE <br />CONTRACTOR L-IVC 0Puz. 6-got:Nv‘le_cisivvkervTAL PHONE 3 La c! '011 <br />CONTRACTOR ADDRESS '+0 1 (A-) • 0 A14. ST • <br />Gay/STATE/Zip I-01> C—et <br />LICENSE 0 1C-42 00C-36 OTHER C 6' NUMBER ( <br /> <br />EXPIRATION DATE 4 -70 - <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X <br /> <br />INSTALLATION WILL SERVE: 0 RESIDENCE <br /> <br />0 COMMERCIAL 0 OTHER <br /> <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br /> <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />GREASE TRAP <br /> <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br />LIFT STATION <br />SIZE TYPE OF PUMP PKG TX PLANT <br />CI SAND OIL SEPARATOR (ENCLOSED SYSTEM) :53311CRIV allS ID LEACH LINES <br />FILTER BED <br />MOUNDED <br />3 SUMPS <br />DISPOSAL PONDS <br />SEEPAGE PITS <br />DISTANCE TO NEAREST <br />WIDTH <br />DISTANCE TO NEAREST <br />WIDTH <br />DISTANCE TO NEAREST <br />WIDTH <br />DISTANCE TO NEAREST <br />DISTANCE TO NEAREST <br />LEACHING CHAMBERS # OF LINES <br />WELL ft FOUNDATION <br /> <br />ft LENGTH ft <br />WELL <br />ft LENGTH <br />WELL <br />ft LENGTH <br />WELL ft FOUNDATION <br />LENGTH OF LINES <br />ft PROPERTY LINE <br />DEPTH <br /> ft DEPTH <br /> ft DEPTH <br />ft FOUNDATION ft PROPERTY LINE <br />ft FOUNDATION ft PROPERTY LINE <br />SAN <br />filARft1 <br />fie,447H ON ft PROPERTY LINE <br />(kip DEPTH <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ft DEPTH ft <br /> ft FOUNDATION ft PROPERTY LINE ft <br />WIDTH ft LENGTH ft <br />NumaER WIDTH <br />DISTANCE TO NEAREST WELL <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION 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 />MINIMUM OUR ADVAN9E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 <br /> -m-LE ego.) . DATE -3- <br />et. 1 <br />/.\ <br />DEPARTMENTIJSE ONLY <br />Application Accepted By Date 3.//p Area 11 C Employee ID# <br />Final Inspection By Date 0 SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Check#/ )...., Amount Date <br />i • <br />Permit/ <br />Service Request # Invoice # Permit ID# Remitted <br />,13 00 5.33 ...d62-- jei,2o4.--Is-- ?)iluri, c,1--1)NDIL-1- <br />l <br />42-01 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18