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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 465-3420 <br />NON-KEFUNDABLE PERMIT <br />JOB ADDRESS T/ <br />� <br />CROSS STREET �j hero' <br />OWNER NAME R- r41 <br />GALL ?U9) 953-IUYI FOR INSPECTIONS <br />CITY/ZIP <br />(d� APIN dJ 3'-L O6 <br />EXPIRES 1 YEAR FROM DATE ISSUE <br />PARCEL SIZE <br />OWNER ADDRESS S e'i rO P CITY/STATEIZIP <br />CONTRACTOR ' Yllyzil Vf�(ille� C- PHONE —0 9f <br />CONTRACTOR ADDRESS J % 'l `� l ` tr�:�% ✓'[/ /y Y' CITY/STATEIZIP <br />LICENSE ❑K-42 ❑CIC -36 OTHER NUMBER ! 5/O�S EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: <br />❑ PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADC <br />Coordinates X Y <br />LAND USE APPLICATION # <br />)N ❑ ENGINEER DESIGNED /ALTERNATIVE <br />❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: (3) NUMBER OF EMPLOYEES: <br />❑ <br />❑ <br />❑ <br />SEPTIC TANK <br />GREASE TRAP <br />LIFT STATION <br />TYPE/MFG 6 y)'s4-7 Ve <br />TYPE/MFG J <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />ft <br />CAPACITY <br />CAPACITY <br />FOUNDATION <br />❑ PKG TX PLANT ❑ <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />X <br />LEACH LINES <br />❑ LEACHING CHAMBERS <br />Area <br />�1�, f <br /># OF LINES C- ) LENGTH OF LINES 7L' ft <br />Final Inspection By s <br />; iCE> l�vufc;o i� <br />DISTANCE TO NEAREST <br />/ <br />WELL / 3o <br />ft <br />FOUNDATION <br />0 <br />ft PROPERTY LINE rJ , ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />Of oF1P bed(06m. <br />Care line is r1f <br />ft <br />DEPTH ft <br />c4,/'- �✓� i� <br />:b <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY UNE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft 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 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 WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NE/AAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />, <br />SEEPAGE PITS <br />NUMBER T <br />WIDTH <br />- <br />ft DEPTH oZ 5 ft <br />DISTANCE TO AREST <br />WELL 1464PO " <br />ft <br />FOUNDATION <br />l.00 s <br />ft PROPERTY LINE /5" ft <br />f 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 />U <br />PE <br />Code <br />ZDEPARTMENT <br />i� <br />USE ONLY <br />�� % <br />/ <br />Date <br />Application Accepted By <br />Invoice # <br />Date S <br />Area <br />Employee ID# <br />Final Inspection By s <br />; iCE> l�vufc;o i� <br />Date i M i '— <br />❑ SPECIAL PERMIT <br />-Approved by <br />Character of Soil to De th of 3 Ft: <br />Pit/Sump Soil Character: <br />COMMENTS Fc1 <br />�e y r ffo, {6'm 6corOltot' o✓7r I/rIe <br />c.z,N b d.)sF <br />for tU?U+e c'ac%117� <br />Of oF1P bed(06m. <br />Care line is r1f <br />r o6)r o,1.,7C)' one Ij'YIe 6r <br />ay?f/� ed room <br />c4,/'- �✓� i� <br />:b <br />IPIY1 <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Check <br />--CTs-h <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />L1210 <br />I I S <br />30o <br />f <br />e'L <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />pz <br />