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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 <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUE[ <br />/ U <br />JOB ADDRESS 17 "� 1 -Q - <br />❑ <br />CITY/ZIP <br />CROSS STREET PPI6 1 I �% <br />Permit ID# <br />APN D-773-303; <br />PARCEL SIZE v <br />OWNER NAME �a 1 e e 3 h r %S�J <br />7h e)- F ! ✓l lc <br />LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />OWNER ADDRESS 7 S 4./4Y <br />/O <br />CITY/STATE/ZIP S <br />CONTRACTOR Cu14 VC(/%L <br />ft <br />PHONE PO <br />�/}j✓,PHONE <br />/ % — -0��/y <br />Y7� <br />CONTRACTOR ADDRESS /�7 <br />/�,�� <br />l/�— !�� CITY/STATE/ZIP <br />�l K l✓%� 7 S�% <br />LICENSE ❑(C-42 ❑0C-36 OTHER <br />ft <br />NUMBER /EXPIRATION DATE <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />WATER TABLE DEPTH: 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 />❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM FI DESTRUCTION <br />INSTALLATION WILL SERVE: pRESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: ` NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ <br />SEPTIC TANK TYPE/MFG �Xf s ✓I CAPACITY <br />gal # OF COMPARTMENTS <br />Chec <br />Cas <br />❑ <br />GREASE TRAP TYPE/MFG CAPACITY <br />gal # OF COMPARTMENTS <br />Invoice # <br />Permit ID# <br />DISTANCE TO NEAREST: WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />S120051011-4 <br />LEACH LINES I LEACHING CHAMBERS # OF LINES <br />r <br />LENGTH OF LINES yo <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />FILTER BED WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />SUMPS WIDTH Y ft LENGTH /Y <br />ft DEPTH A , <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />I HEREBY <br />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 <br />COUNTY. <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) <br />2C���— TITLE <br />SIGNED O 1<2- <br />/9553-7697 <br />— DATE 4—' O� <br />DEPARTMENT U E ONLY <br />Application Accepted By 1 Date LIS Area Employee ID# <br />Final Inspection By —'A' Ah tq Date y "V-zo ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS tj-Dr - lr `epk, r -T-)'Pr ,� - Re h (c <br />paofI, 1 All ,,fhe/ <br />r- j►7P5 it, 7Li <br />ekrtilh. a( onnfr' <br />1F IOLI11!411!4 n <br />bTnlll L 1-10 C Id,),LP <br />Pit/Sump Soil Character: <br />�P.L;l.1�I �fYIeS oi� berrvtli S'373 Cf Pi✓VJ <br />n <br />4 <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Chec <br />Cas <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />al <br />Hs- <br />z <br />43-00 <br />-91Z <br />S120051011-4 <br />42-01 <br />4/14/18 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />T <br />