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MOM, F 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 F OM DATE ISSUED JOB ADDRESS A s^ CITY/ZIP CROSS STREET C/ e,,-e, e e /� APN (/U v ( �0� 3 PARCEL SIZE OWNER NAME Yl e`l �, !/� Spfl PHONE OWNER ADDRESS 3r a / CITY/STATE/ZIP � CONTRACTOR 1 /� `��`y`y�� /,/y�A51 41� //l/ PHONE 15117//(�// �V CONTRACTOR ADDRESS �O l ,2/ Q7 j� / CITY/STATE/ZIP V e �f (////', �/A �j 3/bl LICENSE 1C-42 ❑' 'C-36 OTHER NUMBER !/( v 5 EXPIRATION DATE �� WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION J r IV REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE Po' / REPLACEMENT !�7 OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: It/RESIDENCE I I COMMERCIAL I I OTHER NUMBER OF LIVING UNITS: �NUMBER OF BEDROOMS: 1 -3 NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG w G S` d CAPACITY J gal #OF COMPARTMENTS_ (/❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft 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 ZQ 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 ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft Ir1 SEEPAGE PITS NUMBER WIDTH!/ ft DEPTH .� ft DISTANCE TO NEAREST WELL�DO ; / ft FOUNDATION � ft PROPERTY LINE �O ft 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 H UR DV NCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 r �/ SIGNED TITLE DATE `—.z/ rl DEPARTMENT SEONLY Application Acceptedi By Date Area Employee ID# Final Inspection By Date kl2 ❑ SP CIAL PERMIT-Approved by Character of Soil t Depth of 3 Ft: RAUSump Soil haract r: COMMENTS t*.. J LL 6" . -S . PE SC Received Check#/ Vount Date Permit/ Invoice# Permit ID# Code INFO B C sh Remitted Service Request# 62A2 a 1 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18