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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-REFUNDA13LE PERMIT n CALL(209)953-7697 FOR INSPECTIONS (EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS 538 Z Al�tH /Qosa/� CITY/ZIP 7 Tod(t'��.! / LA lei- `` a CROSS STREET � �GfaSTL F /ZOAO APN lei- l j o- D7 PARCEL SIZE OWNER NAME SAM,,,�`1 Co'+� PHONE 9i�f4/� -7781 o K, OWNER ADDRESS PO 8� ��«2' CITY/STATE/ZIP LlNpe"i I CA 9sZ3(o CONTRACTOR 7—* l•-S7— PHONE CONTRACTOR ADDRESS PO ,Box �5�2- CITY/STATEIZIP 1—ir'oi Nj CAr 1?S23to LICENSE ❑I'C-42 DIC-36 OTHER A NUMBER CJ.3900 EXPIRATION DATE 10 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # (BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION 11 REPAIR/ADDITION I:' ENGINEER DESIG ED/ALTERN PVE REPLACEMENT I': OUT-OF-SERVICE SEPTIC SYSTEM 'fi DESTRUCTION INSTALLATION WILL SERVE: C RESIDENCE ❑ COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: El SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS El GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft E3 LIFT STATION SI7_F_ TYPE OF PUMP 13 PKG T)(PLANT Q SAND OIL SEPARATOR(ENCLOSED SYSTEM) E3 LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY I INE ft E3 FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft E� MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LILAC 'eft. C] SUMPS WIDTH ft LENGTH ft DEPTH SIC DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LII 1' It E] DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERT s'q�/,/pq 1� ft El SEEPAGE PITS NUMBER WIDTH ft DEPTH__ hRpN CpU� _ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPER I Y LIi 11 r&DEPTH—__ ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNT`(ORDWANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMUild 48 HO ADVANCE NOTICE RE UIRED FOR INSPECTIONS - PLEASE CALL 209 953-769,77 SIGNED TITLE i� DATE 1'^ I D DE ARTIUIE TP SE jO_NLY Application Accepted B Date Area Employee ID#� Final Inspection By Date_ _ ❑ SP IAL PERMIT-Approved by Character of Soiltof 3 Ft: _ it/Sump Soil Character: COMMENTS, `A16ALL- L�� PE SC Received hec Amount Permit/ Code INFO B sh emitted Date Service Re uest# Invoice# Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18