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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 />NUN-KLIE UNDABLE PERMIT (:ALL (YUY) <br />yb3-/6y/ FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUE! <br />JOB ADDRESS <br />n <br />VND;IJC ,S70 c - k_�C) <br />A1 CITY/ZIP -75-2d <br />LEACH LINES <br />CROSS STREET _ C✓•�IO� <br />� <br />APN 0 �� 1 <br />PARCELSIZE 7,39 <br />OWNER NAME c"J <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION 0 ft PROPERTY LINE $ f <br />-PHONE <br />OWNER ADDRESS <br />V�LJ/��,1 <br />CITY/STATE/ZIP <br />ft DEPTH <br />ft <br />CONTRACTOR ��))J�� <br />PHONE <br />FOUNDATION ft PROPERTY L`FNE <br />CONTRACTOR ADDRESS <br />f'T^ r_ 4% I1-Yoy Li <br />CITY/STATE/ZIP <br />WIDTH ft LENGTH <br />LICENSE 111..'C-42 ❑ ',C-36 OTHER <br />NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION REPAIRIADDITION C ENGINEER DESIGNED /ALTERNATIVE <br />l REPLACEMENT I i OUT -0F -SERVICE SEPTIC SYSTEM I DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ <br />❑ <br />❑ <br />SEPTIC TANK <br />GREASE TRAP <br />LIFT STATION <br />TYPE/MFG £ e� l 1�1 <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL ft <br />SIZE TYPE OF PUMP <br />CAPACITY 00 gal # OF COMPARTMENTS <br />CAPACITY gal # OF COMPARTMENTS <br />FOUNDATION ft PROPERTY LINE <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />ft <br />Permit/ <br />Service Request # <br />LEACH LINES <br />❑ LEACHING CHAMBERS I <br /># OF LINES LENGTH OF LINES /00 • <br />ft <br />3 i <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION 0 ft PROPERTY LINE $ f <br />ft <br />AFILTER <br />BED <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY L`FNE <br />ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ <br />SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ <br />SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL It <br />FOUNDATION ft PROPERTY LINE <br />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 />DATE <br />T <br />J / DEPARTMENT U&E ONLY <br />Application Accepted BBy, Date /cP Area 3 Employee ID# A <br />/" <br />Final Inspection By Date 9'�3 ZZ ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS Ncn'rev6;r - 1)"P - 1L 1`ZP,ri,,,:�� "N- 74 4i/\/ 1D l,nrs to verm ccs bv:ld- )'n 0,- isi1: <br />ruCferi,c,up✓ 1Fuiln 1„��� Lecch 1�>7P �h�,�� »oT be C'.lYaV <br />PE <br />Code <br />SC <br />INFO <br />Received Check#/ <br />B Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />I- a ►a <br />j5- s <br />3 i <br />g• g- <br />Si200 °i <br />42-01 N"65 <br />"65 CV 2— cl 7'4— ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />:.I <br />