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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 JOB ADDRESS CROSS STREET Y� 1 APN O ' ` /'7 GJ ✓ PARCEL SIZE OWNER NAME n� S r G be I PHONE SSI 6 ( ove LrPcl� C s„ 54 UCK+G C1S2o� OWNER ADDRESS /STATE/ZIP Q� s CONTRACTOR C PHONE(% • �_+� • _�OV / CONTRACTOR ADDRESS ;)!i h [j�•�� CmV/STATEMP 442 ��j��G"� ?9-0% Y�•- LICENSE : P42 C-36 OTHER NUMBER # 5-w EXPIRA71ON DATE q- a WATER TABLE DEPTH: Ok---J it GEOGRAPHICAL INFORMATION: Coordinates X Y SIGNED DATE f — `J N d b LYMENT CEIVED R 0 5 2018 JOAQUIN COUNTY WRONMENTAL LTH DEPARTMENT K;., -) dov>I Application Accepted By Final Inspection By_ Character of Soil to Deptl COMMENTS <-4 Z 1111 11 Ill 11111111111111111-M r DE PAR T ME T USE ONLY /j 0 Date - j " I Y {vAt'rea �� Employee ID# "" L �j Date SPECIAL PERMIT -Approved by Y 3 Ft: PIt/S mp Soll Charact ( qji 'It la WD AA JA IL -11 h PE SC Received Chec Amount Permit/ Invoice# Permit 1D# Code INFO Date ash Remitted Service Request # 2 sq lv 8 SSI s/ l ti C7 s 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 424/12 PERC TEST r BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADornON ENGINEER DESIGNED /ALTERNATIVE LEACH LINES LEACHING CHAMBERS # OF LINES O�- LENGTH OF LINES 60 ft REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL V OTHER_sk*02 RaR.06mw :q + WELL J1d0 NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: �[ xl SEPTIC TANK ^ TYPE/MFG 0IkC CAPACITY Zyo O gal # OF COMPARTMENTS f ❑ GREASETRAP TYPEIMFG CAPACITY gal #OFCOMPARTMENTSS WELL it FOUNDATION ft PROPERTY LINE R d�1 DISTANCETONEAREST: WELL I Yt/ ' it FOUNDATION / V • ft PROPERTYLINE 7 ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT O SAND OIL SEPARATOR (ENCLOSED SYSTEM) SIGNED DATE f — `J N d b LYMENT CEIVED R 0 5 2018 JOAQUIN COUNTY WRONMENTAL LTH DEPARTMENT K;., -) dov>I Application Accepted By Final Inspection By_ Character of Soil to Deptl COMMENTS <-4 Z 1111 11 Ill 11111111111111111-M r DE PAR T ME T USE ONLY /j 0 Date - j " I Y {vAt'rea �� Employee ID# "" L �j Date SPECIAL PERMIT -Approved by Y 3 Ft: PIt/S mp Soll Charact ( qji 'It la WD AA JA IL -11 h PE SC Received Chec Amount Permit/ Invoice# Permit 1D# Code INFO Date ash Remitted Service Request # 2 sq lv 8 SSI s/ l ti C7 s 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 424/12 ' W LEACH LINES LEACHING CHAMBERS # OF LINES O�- LENGTH OF LINES 60 ft 1 DISTANCE TO NEAREST :q + WELL J1d0 n ft FOUNDATION :�' , R PROPERTY LINE pS , It L7 ❑ FILTER BED WIDTH it LENGTH It DEPTH it DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE R ❑ MOUNDED WIDTH it LENGTH it DEPTH ft DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE it ❑ SUMPS WIDTH ft LENGTH it DEPTH it DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH it LENGTH it DEPTH ft DISTANCE TO NEAREST WELL it FOUNDATION It PROPERTY LINE It ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYUNE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,S, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY- M/NIMIIM 9d M(7IIf? AnVAAtRF A/ATICF f7Fn!/IRFI] FnR /AICDF!_T/ANC _ D/ FACE Cdl / /91101 QS27RQ7 SIGNED DATE f — `J N d b LYMENT CEIVED R 0 5 2018 JOAQUIN COUNTY WRONMENTAL LTH DEPARTMENT K;., -) dov>I Application Accepted By Final Inspection By_ Character of Soil to Deptl COMMENTS <-4 Z 1111 11 Ill 11111111111111111-M r DE PAR T ME T USE ONLY /j 0 Date - j " I Y {vAt'rea �� Employee ID# "" L �j Date SPECIAL PERMIT -Approved by Y 3 Ft: PIt/S mp Soll Charact ( qji 'It la WD AA JA IL -11 h PE SC Received Chec Amount Permit/ Invoice# Permit 1D# Code INFO Date ash Remitted Service Request # 2 sq lv 8 SSI s/ l ti C7 s 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 424/12