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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 EXPIRES 1 YEAR FROM DAT SSUED JOB ADDRESS LI L v4 r CITY/ZIP Com= i CROSS STREET n f2 604 APN 'VR/��`�V 7 V Y/0 PARCEL SIZE `� d JIf I qD � o OWNER NAME r ►� `�'C111s' j � ZQ(��,(Q 'n� / PHONE OWNER ADDRESS o 1 [ t(J �Gt`I-�(L c;1 L�1 �/6�ITY/STATE/ZIP L_0<4 ' CONTRACTOR M, j4_a!5 _PS 4jC 40 r. PHONE �1_S� .K�t.S CONTRACTOR ADDRESS y 1`C t.1s:0 CITY/STATE/ZIP �i CYI�CGv�I r Cyq S j�� LICENSE ❑❑C-42 ❑❑C-36 OTHER_4A NUMBER EXPIRATION DATE (�il WATER TABLE DEPTH: ':rklt�� ft GEOGRAPHICAL INFORMATION: COOiCIIn es X Y ❑ PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: V NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE I I REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: j ESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: !I NUMBER OF EMPLOYEES: WY SEPTIC TANK TYPE/MFG (t L CAPACITY ��g _ gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELLf'�7 i ft FOUNDATION ��( ft PROPERTY LINE_S ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) D 'LEACH LINES CI LEACHING CHAMBERS #OF LINES _ LENGTH OF LINES C�( , ft i DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE_ ft 13 FILTER BED WIDTH ft LENGTH ft DEPTH it 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 SEEPAGE PITS NUMBER WIDTH J is I f ft DEPTH pis r ft DISTANCE TO NEAREST WELL ft FOUNDATION Ur-, i 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. MINIMUM 48 HPLO ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 09}53-7697 SIGNED TITLE��,f�C 1j i� DATE EC 1�0 R N ETA H H DEFRM Ni A R T M E NT4SE iNL Y Application Accepted B _ _ Date Area Employee ID# Final Inspection By W&WDate ❑ SPECIAL PERMIT-Approved by Character of Soil to epth of 3 Ft: _ Pitl ump Soil Character: COMMENTS IN (� PE SC Received Amount to Permit/ Invoice# Permit ID# Code INFO By Cash Remitted Service Request# dPVS Z 5M210 ten 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18