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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 ` NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 4219 t. aL..VESTGNE C,1 CITY/ZIP ACA'Mfo y CROSS STREET CL�EA1>STD N E ]>A• APN Q D 3(C'0-O PAARCCEL SIZE Z-of AC• b OWNER NAME r I"G-�l ��! j� PHONE E,. 37-9 - �p�' m OWNER ADDRESS Z'r� !T V /^1. `S- IOW L�S,An 9--b �- CITY/STATE/ZIP Ac A7"P D C'� I Y-Z'2-o CONTRACTOR Ll V C OAI C-� (& 0/7�Vj 94N''I C�T^L PHONE 3 b CI-0 31 s C/ ]� CONTRACTOR ADDRESS TV l W - OAK K 5r' CITY/STATE/ZIP LOW( � •5- •V LICENSE I IC-42 C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST #----L— I BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIRIADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT I DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL It FOUNDATION It PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft ❑ FILTER BED WIDTH It LENGTH It DEPTH ft DISTANCE To NEAREST WELL It FOUNDATION It PROPERTY LINE ft ❑ MOUNDED WIDTH It LENGTH It DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH It LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. INIM M%2�11JR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 p SIGNED /`� ` TITLE C4WSJL 11 AOWT DATE 6— YMENT CEIVED -'A t�,J\j IN 18 2019 SAN QUIN COUNTY ENVIRONMENTAL HEAiTtl DEPARTMENT �(1 DEPARTMEN U E NL Application Accepted B V V Date ' Area .. �� Employee ID# c Final Inspection By Date SPECIAL PERMIT-Approved by Character of Soil to 1`3 t: Pit/ Ump Soil Character: COMMENTS - 3 fA l L il`\ PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO Cash Remitted Service Re uest# I 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT