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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1865 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIR ES 1 YEAR FROM DATE ISSUED JOB ADDRESS � f I YV. f�I�JL ------CITY/ZIP GA -I�22 C7 U CROSS STREET C� EQ I313D (� APN�72,S O ___ PARCEL SIZE OWNERNAME �\YL Kr;st� TT1��5 _ PHONE_ OWNER ADDRESS JJ�� /I7F CITY/STATE/ZIP ✓> CONTRACTOR CD✓t/STIZ(�tCY�O �J >EPT'rc {yr_ PHONE I�ICo) `t79 9%-77 �27ss G� CONTRACTOR ADDRESS �C)aATs�n1 `�� i�-- �'��u�'L ZG�O CITY/STATE/ZIPti✓TD e''9 / Z LICENSE t,�42 LI C-36 OTHER _ NUMBER 9??y3Co EXPIRATION DATE. 0&1-391202- O WATER TABLE DEPTH: - ft GEOGRAPHICAL INFORMATION: Coordinates X __- Y C PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE V// REPLACEMENT AI{�_2_ _ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION 7Ti1y%1V-- 16 INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: __ NUMBER OF EMPLOYEES: SEPTIC TANK TYPEIMFG CCC V,CaC7171= // ? L CAPACITY /ZDV gal #OF COMPARTMENTS 2— ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL !Oc 't ft FOUNDATION 2-c'' ft PROPERTY LINE 3S ft ❑ LIFT STATION SIZE _ _TYPE OF PUMP ___ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES I/ LEACHING CHAMBERS_ #OF LINES 3 LENGTH OF LINES � ft I , DISTANCE TO NEAREST WELL /O(!> 'r ft FOUNDATION ft PROPERTY LINE �� -F— 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 SEEPAGE PITS NUMBER -3 WIDTH /Z ft DEPTH 2 ft DISTANCE TO NEAREST WELL I So ft FOUNDATION /0O, 1 ft PROPERTY LINE 2-' 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. SIGNED TITLEf i��5 )Er> DATE U/Li R N 9 - DEPIRTMENTUSEONLY Application Accepted By Date z z 11q Area Employee ID# S L Final Inspection By A Date ;� SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: - _ _ Pit/Sump Soil Character: COMMENTS s - PE SC Received Check#/ Amount Permit/ Code INFO B Ca�Ash Remitted Date Service Request# Invoice# Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4!14/18