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b ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT C'A'fLL 209 953-7697 FOR INSPECTIONS r _ EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS Lt/3 W/n c- `�44 CITY/ZIP 5{�L�'11 CIC}�S2o. /� y CROSS STREET //V�A\I'V 0rN-c APN 1 3— 236 -yS PARCEL SIZE �- / ^c11§ p OWNER NAME A c1�./�RrY (�D /�1 GS �/ / PHONE ?^01 p`16s OWNER ADDRESS P. O• II�JmJC L�G1�O RC% f J A CITY/STATE/ZIP -L. �� -1.SZOI CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ] C-42 ] C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ] PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM X DESTRUCTION INSTALLATION WILL SERVE: ] RESIDENCE ] COMMERCIAL ] OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTICTANK TYPE/MFG w1pW✓L CAPACITY L1LWSYfaLy-1 gal #OFCOMPARTMENTS uN�NeWN ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE It ❑ 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 ft FOUNDATION ft PROPERTY LINE 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 It ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It DISTANCE TO NEAREST WELL 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. MINI 4 ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 Erwin.SIGNED TITLE win. l�/+ 4? - DATE -7—7-17 YNIENT I lit I f�7i R� T77JkrHF;3,e DEIVED 0 7 2017 SaCAQUIN COUNTY E RONMENTAL f'f`` T I UEr-ARTMENT B PARTMENT SE N Application Accepted B1 Date Area Employee ID# �'� Final Inspection By Date ] SP IAL ER IT-Approved by Character of Soil1t9 Depth of 3 Ftp: Pit/Sump Soil Character: L COMMENTS Vno'-we to Y'tV L 0k� 7� 1�ow1 /YC d K ,uM el A s 6- Coy f/ac �¢ l �" � oG o �4 �✓o I �- �� - ;�ll, oµ>� f ("e>~t K a,�d ��e (ee c��r/tial p, PE SC Received eck# Amount Da Permit/ Invoice# Permit ID# Code INFO B Remitted i Re s z o 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT \\A 5/ / f t/'Q 4124112 Y