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kc>ti a � zob� tidos <br />2c-, 17- <br />ONSITE <br />iONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DrPAATMENT 1868 E. HAzELToN AvENuc - STocKTDN CA 95205 - (209) 468.3420 <br />PION-KEFUNDABLE rFRMTT <br />GALL 7UV V:PJ•/09/ FOR INSPECTIONS <br />tXPRE3 l TEAR FROM DATE I53UEE <br />JOB ADDRESS r;b 1 J <br />6T—A-Tt VcU T7=' t Z <br />CRYIzip L 0 D <br />L 4' S -Z q Z <br />CROSS STREET P%t llZr0 J ?CO A -Q APN b <br />Z S I Q b 15 <br />SUE <br />n�{0 <br />OWNER NAME Ln[ gLi f"5,- <br />R FOUNDATION <br />H PROPERTY LINE R <br />�/PARRCCEEL <br />/.LJ L <br />OWNEKADDRESt3/�16 1rf1 <br />�j Jam/ Q.,A w <br />t4 R Tri • `✓TJ <br />CITTISTATFJZIP <br />(PHONE <br />{ e,c, L � s- -z Y Z. <br />y <br />CONTRACTOR F to -A 4 <br />& lar <br />q <br />PHONE /. IG <br />b L Z nO. % <br />CONTRACTOR ADDRESS LOS <br />q_�t rat <br />LJ O(rD PL%��\LLLL'i� <br />RC). CmISTATFJZIP <br />q <br />5/�')r_aAoy-,.cTD l9eeZ <br />UcEN3E _: C-42 U C-30 <br />OTHER NUMBER <br />EXPIRATION DATE <br />DISTANCE TO NEAREST WELL <br />WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X .YD.(l q Z Y -i - t . 56}Syc L <br />PERC TEST # BUILDING PERMIT # LAND USE APPUCATLON <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDnION }< ENGINEER DESIGNED IALTERNATrvE <br />REPLACEMENT OUT-0F.SERvICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: ,_i RemneNCe D COMMERCIAL XOTHac Ihtpu�T'n•/a1.- W <br />NUMBER OF LNWG UNITS: NUMBER OF BEOROOMS. NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPEIMFG <br />CAPACITY <br />981 #OFCONPARTMENTS <br />❑ GREASETRAP <br />TYPE/MFG <br />CAPACITY <br />gal #OFCONPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />R FOUNDATION <br />H PROPERTY LINE R <br />O LIFT STATION <br />SIZE TYPE OF PUMP <br />Ll PKG TX PLANT <br />O SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />LEACHING CHAMBERS <br />OF LINES <br />LENGTH OF LINES it <br />DISTANCE TO NEAREST WELL <br />R FOUNDATION <br />It PROPERTY LINE It <br />❑ FILTER BED <br />WIDTH ft LENGTH <br />N DEPTH It <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />It PROPERTY UNE It <br />❑ MOUNDED <br />WIDTH It LENGTH <br />ft DEPTH N <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY UNE R <br />❑ SUMPS <br />WIDTH ft LENGTH <br />It DEPTH ft <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION <br />f1 PROPERTY UNE it <br />❑ DISPOSAL PONDS <br />WIorN It LENGTH <br />R DEPTN It <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION <br />ft PROPERTY LINE it <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />N DEPTH ft <br />DISTANCE TO NEAREST WELL <br />R FOUNDATION <br />R PROPERTY UNE It <br />I HERESY CERTIFY THAT 1 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 />HOUR NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL (2091953-7697 <br />MINIMUM 48 <br />SIGNED <br />ADVANCE <br />TITLE <br />- <br />DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By _ Z 1 , Date -7 Area / �� (� Employee IDN / <br />Final Inspection By IT v k Data U SPECLAL PERMIT -Approved by <br />Character of Soil to Depth oY3 Ft: Pi <br />t <br />/Sump Soil Character: _ <br />COMMENTS k« Z Z - gkrL z4l- - Q l <br />PE SC Received i Amount Date Permit/ Invoice # Permit IDN <br />Code INFO B Remitted Swvice Request A <br />-Iaa,;' sJ3 u W, SIO W <br />44211-041 <br />,6 1 -L a Lb b T �7r /,, Z2 <br />t q (o 2_2-3 TSV i L <br />PAYMENT <br />RECEIVED <br />JUL 0 1 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Ra <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />