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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 EXP IRES 1 YEAR FROM DATE ISSUED JOB ADDRESS o. GON CITY/ZIP TS`-=oiS U CROSS STREET �y�GOiJ J A/1/� /ZO APN \ LJ I ' PARCEL SIZE A"� d o a v OWNER NAME �`G/i7/v//7//O/V / 7iP/�. / �� d- OWNER ADDRESS 3y_3 �///e".? CITY/STATE/ZIP gy 0.7,Z '/, v CONTRACTOR / ; G�a/✓fy PHONE J -o/ a CONTRACTOR ADDRESS �J CITY/STATE/ZIP LICENSE ❑CIC-42 ❑IJC-36 OTHER _Z/ 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 11 ENGINEER DESIGNE ��.1/LT••E--R..N''ATI`V`E REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION J (/ VV+ INSTALLATION WILL SERVE: I I RESIDENCE I I COMMERCIAL ( � OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG CAPACITY 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 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 /(�� 7 ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERT)aQ �T 20to ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ZAA"'��11 ap Q ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPER NUJ Ute-NTV ft L3DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH gRTgf�N�ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 1 HEREBY CERTIFY THAT I HAV EPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, ST TE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMUM 4 OUR ANCE NOTICE REQUIRED FOR/NSP IONS-P SE CALL (209)953-76,97 SIGNED TITLE `ET OL DATE -r// apt 0" 7-7. 111M11111 ii 1 \ DEPARTMENWUSENLYApplication Accepted By Date . Area Employee ID#Final Inspection By Date ❑ SP IAL PERMIT-Approved by Character of Soil to De th of 3 Ft: C aracte COMMENTS ��4L %AL_ cti � LOC rn��:"ft� r t.�IF I JC S e.i?7�C t-a KS -f�tt PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO B Cash Remitted Service Request# (� S �S 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18