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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 BF4ZMIT PALL 2209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS S (/ CITY/ZIP CROSS STREET APN_4 (J &0 PARCEL SIZE � V � OWNER NAME �S/d< c So 1�'1 L- LLL PHONE ( OWNER ADDRESS I `� 'J S. 1 S A V 1/J CITY/STATE//ZIIPP <�/J yJ q S 4 ` v CONTRACTOR ' ' PHONE CONTRACTOR ADDRESS n CITY/STATE/ZIP, /✓�� C/; v� ��/ LICENSE ❑I.IC-42 1]lJC-36 OTHER i� NUMBER G' "EXPIRATION DATE J WATER TABLE DEPTH: I ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# 0 1 LAND USE APPLICATION I# TYPE OF WORK: NEW INSTALLATION I I REPAIR/ADDITION I I ENGINEER DESIGNED/ALTERNATIVE I] REPLACEMENT I I OUT-OF-SERVICE SEPTIC SYSTEM f DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE I I COMMERCIAL` I_I OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: / NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG t�� CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL( ft FOUNDATION !' 7 ft PROPERTY LINE _S J-1'J ft LJ LIFTSTATION SIZE TYPE OF PUMP LIPKG TX PLANT SAND OIL SEPARATOR(ENCLOSED SYSTEM) /xL LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft VV DISTANCE TO NEAREST WELL ft FOUNDATION /( f ft PROPERTY LINE 1i' �' 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 ft FOUNDATION ft PROPERTY LINE ft ❑ 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 NEEST WELL ft f)OUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER WIDTH tz� J/ ft DEPTH : 4—) ft DISTANCE TO NEAREST WELL—/519 ft FOUNDATION / ft 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. Ml M 48 HOU DV CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE (/ DATE Ju w--A iI-GauL H Ef AR TM N DEPARTMENT USE ONLY Application Accepted Date • -Q L ") 9 Area "/ V/ Employee ID# Final Inspection By Date 2 ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received Amount Date Permit/ Invoice# Permit ID# Code INFO B Cash Remitted Service Reg uest# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18