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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 GALLZU9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS 3 3(p LW (rTTEP- S Rb • CrrY/z�-IPXEAX-I� COVAI P 9 S L3 1 <br />CROSS STREET MC- KIN Ley APN 123-310 -C)+ PARCE,LfSIZEQfArC <br />OWNER NAME M M?•/k n!f'c4 lam" /� (�z-VIZ f� A•V M2P—(] PHONE <br />OWNER ADDRESS S PYVMVN j CRY/STATE/ZIP <br />CONTRACTOR L l V Cv G0,j VL` ��'O ) 9 e/j I't's EN' F AL PHONE 30 -03-1 S p <br />CONTRACTOR ADDRESS 4 D-1 w • (L'W- ST ` CRY/STATE21P L db I C6 CfS')- L1U <br />LICENSE 00C-42 00C-36 OTHER C Ey NUMBER Z(S ( EXPIRATION DATE `F - 30 -- 2-2- <br />WATER <br />'Z <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />iy- PERC TEST # <br />k I BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />D NEW INSTALLATION CI <br />REPAIR/ADDITION <br />C1 ENGINEER DESIGNED/ALTERNATIVE <br />ft <br />0 REPLACEMENT I..I <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />0 DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />ft <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES I':.7 LEACHING CHAMBERS <br /># of LINES LENGTH OF LINES ft <br />ON <br />DISTANCE TO NEAREST <br />WELL <br />DEPTH ft <br />ft FOUNDATI <br />FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft PROPERTY LINE ft <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft PROPERTY LINE ft <br />ft FOUNDATION <br />MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />SUMPS <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ON <br />ft PROPERTY LINE ft <br />ft <br />DEPTH ft <br />ft PROPERTY LINE ft <br />ft <br />DEPTH It <br />ft PROPERTY LINE ft <br />ft <br />DEPTH It <br />ft PROPERTY LINE ft <br />It <br />DEPTH ft <br />ft PROPERTY LINE ft <br />ft DEPTH ft <br />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 />SIGNED <br />vn 11V0V=k11 vulva - ILVDI JJJ-I V. r <br />TITLE f'- DJ • wl G f2— DATE �f - 30 -- 2 <br />�. DEPARTMENT USE ONLY l� <br />Application Accepted By �?-�" < - Date x'1301 Area % Employee ID# IF6 <br />Final Inspection By Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />PE SC Received Check # Amount a PgrmiU Invoice # Permit ID# <br />Code INFO Remitted Service Request # <br />Lana -"-23 visa <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />