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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 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES/1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP LiLt9 O. ( � / '` m CROSS STREET ('-0///C'- APN PARCEL SIZE-+ o O OWNER NAME M ory_ oL/G � PHONE o2c'% A1C/ 7` _-57 OWNER ADDRESS CITY/STATE/ZIP J CONTRACTOR N1 LI ' /V"(l `^'/ �Y�/' C PHONE CONTRACTOR ADDRESS y � / � 01 5-GL,, I�� JJ C� CITY/STATE/ZIP y LICENSE ❑I c-42 0IIC-36 OTHER NUMBER -T�/Q�S EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# Z.2LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION I REPAIR/ADDITION I I ENGINEER DESIGNED/ALTERNATIVE I I REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM I I DESTRUCTION INSTALLATION WILL SERVE: / RESIQENCE 11 COMMERCIAL El OTHER NUMBER OF LIVING UNITS: a"4 U11 1 7L NUMBER OF BEDROOMS: -3 NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG (loorrfk hp"s CAPACITY l/(1/00 gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY 1 gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL �U U ft FOUNDATION / r ft PROPERTY LINE (Jl ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) tXLEACH LINES I I LEACHING CHAMBERS �u #OF LINES j LENGTH OF LINES SS , ft DISTANCE TO NEAREST WELL 00 It FOUNDATION 30 ft PROPERTY LINE r/� ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NO REST WELL ft FOUNDATION ft PROPERTY LINE ft 13 SEEPAGE PITS NUMBER WIDTH 4yN Q ft DEPTH Z-:5-( ft DISTANCE TO NEAREST WELL C.1 flFOUNDATION 9O ft PROPERTY LINE It 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. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 SIGNED ' TITLE DATE nit q 2®19 HH1 A rq� FNT DEPARTMENT USff ONLY Application Accepted By Date Area Employee ID# Final Inspection By Date `�� El SP_ IAL E MIT-Approved by IF Character of Soil to Dept of 3 Ft: PiVSump Soil Character: COMMENTS In- PE SC Received he Amount Date Permit/ Invoice# Permit ID# Code INFO B s Remitted Service Request# 47A 1/7 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18