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ONSITE WASTEWATER TREATMENT SYSTEM P=ERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />N LJN-rCtr'UNUAt5Lt I-tKMI I <br />C:FILL (ZUy) -90J-/tiY1 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS of5/`7� CITY/ZIP 44,4 P?,0C, L <br />CROSS STREET eO//' ate- / APN00% Z�6 -J � PARCEL SIZE �J <br />OWNER NAME la{(y�/' PHONE <br />OWNER ADDRESS d 5 1+O IV, Pl�e`a r CITY/STATE/ZIP <br />-5-OZ-7CONTRACTOR aii//� /�'C% yy� PHONE <br />_ C7/ " <br />CONTRACTOR ADDRESS 3 7Y/. �//. 6/e /i�i�G t�;W CITY/STATE/ZIP <br />LICENSE [11]IC-42 ❑ ❑C-36 OTHER NUMBER y� EXPIRATION DATE <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # <br />BUILDING PERMIT# �;G��I7o2 LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />Invoice # <br />REPLACEMENT 0 OUT -0F -SERVICE SEPTIC SYSTEM C DESTRUCTION <br />INSTALLATION WILL <br />SERVE: P�- RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING <br />UNITS: 1 NUMBER OF BEDROOMS: -�? NUMBER OF EMPLOYEES: <br />�— SEPTIC TANK <br />TYPE/MFG .44 CAPACITY �(��i/c� gal # OF COMPARTMENTS C4 <br />❑ GREASE TRAP <br />TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ZC� ft FOUNDATION ft PROPERTY LINE 5-o I Y ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />V LEACH LINES <br />❑ LEACHING CHAMBERS # OF LINES _ LENGTH OF LINES SS ft <br />DISTANCE TO NEAREST WELL Z60 ft FOUNDATION ft PROPERTY LINE �d r ft <br />❑ FILTER BED <br />WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />tf—SEEPAGE PITS <br />NUMBER WIDTH yew ft DEPTH$- ft <br />DISTANCE TO NEAREST WELL % ft FOUNDATION ft PROPERTY LINE rr 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 />TITLE <br />DATE <br />DEPARTMENT U E ONLY <br />Application Accepted tBy �/�LL Date s �� •Z Area y 9 Employee ID#� <br />r <br />Final Inspection By femu��y L""/I%c, A4,A. Date (2j3122, ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: 1 <br />COMMENTS Nor rept.1 r - 'rl&r Jr, AN), PeAr% crSSac 1Cn %eG1 a, 7"h PArI@ r. <br />PE <br />Code <br />Sc <br />INFO <br />Received <br />By <br />hec <br />Cash <br />Amount <br />Remitted <br />Date Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />ydl <br />II -7 <br />#C -3I <br />ti ,J <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />