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I , 16 <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NL)N-MtF-UNUAI3Lt rEHMI I <br />GALL ZUy ybJ-/by/ FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUEI <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />Invoice # <br />JOB ADDRESS _.11¢ 41 <br />gal # OF COMPARTMENTS <br />`r <br />BTW V p CITY/ZIP 41 hd`%\ <br />4 CLQ' <br />WELL ft <br />CROSS STREET <br />)—m e. K-d/l, APN 1015- - 2 60 0 - (9 PARCEL SIZE <br />fl C:) <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />IB, -L -EACH LINES <br />LEACHING CHAMBERS <br />OWNER NAME 1-_-) 1�3h/ <br />o <br />/Jl_ W�T^1�1 epi/ �7 Q�7 <br />PHONE <br />DISTANCE TO NEAREST <br />OWNER ADDRESS <br />FOUNDATION <br />/ ri. U7 /��- L� �p CITY/STATE/ZIP <br />> A <br />v/ -%w -e'% <br />WIDTH <br />CONTRACTORI/► <br />I tI/��� <br />�� <br />/iC jCL J PHONE <br />DISTANCE TO NEAREST <br />CONTRACTOR ADDRESS <br />FOUNDATION <br />j a & q p CITY/STATE/ZIP <br />Ana <br />G/y7L��rfl ���4 <br />/ o� <br />533& <br />LICENSE ❑ - C-42 ❑ <br />C-36 <br />OTHER aCJ NUMBER ZS�SS j EXPIRATION DATE <br />DISTANCE TO NEAREST <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 DESTRUCTION <br />INSTALLATION WILL SERVE:RESIDENCE ❑ COMMERCIALLl OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: -JQ NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />Received <br />B <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />Invoice # <br />CAPACITY <br />gal # OF COMPARTMENTS <br />i� <br />DISTANCE TO NEAREST: <br />WELL ft <br />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 />IB, -L -EACH LINES <br />LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES iOt ft <br />DISTANCE TO NEAREST <br />WELL 60 I ft <br />FOUNDATION <br />ft PROPERTY LINE S4 1 ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />U --"SEEPAGE PITS <br />NUMBER a. WIDTH 30l' <br />ft DEPTH a-$ ( ft <br />DISTANCE TO NEAREST <br />WELL6! ft <br />FOUNDATION C�� ft PROPERTY LINE SG' 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 />IVII/VIIV/V/V/ 48 17VUfC tjLJVAiVLC IVV IILC MC WRCIJ rUf% 11VJrCIi►IV/VJ - rLCNJC Um LL IZU. <br />SIGNED TITLE 45/Orifi` reo� DATE <br />DEPARTMENT U E ONLY G( IF 6? e <br />Application Accepted By Date Z Area / / Employee ID# <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 <br />Code <br />Sc <br />INFO <br />Received <br />B <br />,­Cfi_ecW <br />Amount <br />emitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />y2/o <br />i� <br />300 <br />3 <br />22 <br />�5 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />cn <br />