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t <br />N <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE -STOCKTON CA 95205 -(209)468-3420 <br />NON-KEFUNDABLE PERMIT <br />GALL ZZU9 953-1692 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS <br />L L <br />//y�J <br />CITY/ZIP e& <br />�G4zod / 2 / Z <br />❑ <br />� �C)G � T <br />- <br />©ff6 - <br />#1s6 <br />CROSS STREET <br />5 <br /># OF LINES <br />APN �O (/ <br />PARCEL SIZE 1,73 <br />/� /q <br />OWNER NAME (1 �y^{C,O/_xl/ <br />©dU <br />DISTANCE TO NEAREST <br />2a -32 17- Zf <br />, <br />OWNER ADDRESS �J �/ ✓O <br />�C fJ�G / <br />C�i9CITY/STATE/ZIP <br />`PHONE <br />(/?(� � / /� / � <br />�- <br />CONTRACTOR _ <br />r <br />PHONE <br />C��,� <br />�/ /15 / <br />ft <br />LENGTH <br />-( <br />�O� <br />CONTRACTOR ADDRESS 1�/ <br />/L J / <br />CITY/STATE/ZIP <br />14 <br />LICENSE ❑ _ C-42 []-IC-36 <br />OTHER li L <br />C�y^ <br />NUMBER l / ?EXPIRATION DATE z z, <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION <br />❑ PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: _ NEW INSTALLATION REPAIR/ADI <br />Coordinates X <br />LAND USE APPLICATION #. <br />IN ENGINEER DI <br />Y <br />REPLACEMENT OUT -0F -SERVICE SEPTIC SYSTEM KDESTRUCTION _ t 1, )i <br />INSTALLATION WILL SERVE: ov, RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />ATIVE <br />❑ <br />❑ <br />SEPTIC TANK <br />GREASE TRAP <br />LIFT STATION <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />ft <br />CAPACITY <br />CAPACITY <br />FOUNDATION <br />❑ PKG TX PLANT <br />❑ <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />LEACHING CHAMBERS <br />#1s6 <br />5 <br /># OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH fl <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <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 />DEPARTMENT USE ONLY / <br />Application Accepted By - G� Date —7/,2 Area 1 Empl4u <br />Final Inspection By Date d: I G A ❑ SPECIAL PERMIT -ApplR ei� � <br />Character of Soil to Depth of 3 Ft: Pit/ ump Soil Character: <br />COMMENTS 4,4 Jj/ 9.9 yAn.. <br />SAN in., <br />We�WUIN COUNTY <br />RgNili ra <br />PE <br />Code <br />SC Received <br />INFO B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # Invoice # <br />e <br />q;511 <br />075 <br />15 <br />#1s6 <br />5 <br />42-01 C ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 lll�i� I V <br />T <br />a <br />