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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 DATE ISSUED JOB ADDRESSa� rrc t6 ijq y-L CITYIZIP G' t � CROSS STREET t�c�Ao�� 1�-tom A P N�'�� 7 PARCEL SIZE Z` C t M r c OWNER NAME C '�]T- A PHONE OWNER ADDRESS I Ln-) ��t�/[, V�}�{_ �f CITY/STATE/ZIP &I �L I� /? �nF CONTRACTOR L-C'S ��(��.�L y! PHONE _ CONTRACTOR ADDRESS "7 _�c"z [L S!� CITY/STATE/ZIP LICENSE 111IC-42 110C-36 OTHER _ NUMBER % S EXPIRATION DATE_ WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: COordln es X Y ❑ PERC TEST # BUILDING PERMIT# AND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION I-) R PAIR/ADDITION ❑ GINEER DESIGNED/ALTERNATIVE REPLACEMENT 0 OUT-OF-SERVICE SEPTIC SYSTEM Vr DESTRUCTION659 � INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: y� NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: Lr SEPTIC TANK TYPE/MFG iF a.. CAPACITY CP amp gal #OF COMPARTMENTS E3 GREASE TRAP TYPE/MFG CAPACITY _ gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL FOUNDATION ft PROPERTY LINE ��t- _ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT LJ SAND OIL SEPARATOR(ENCLOSED SYSTEM) _ —..-------- LEACFI LINES ❑ LEACHING CHAMBERS #OF LINES` LENGTH OF LINES / ft DISTANCE TO NEAREST WELL 0 0 r ft FOUNDATION (Q ft PROPERTY LINE �n t _ ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft C 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 G DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft �} I SEEPAGE PITS NUMBER H WIDTH - C, ft DEPTH•S-I ft DISTANCE TO NEAREST WELL Sn ft FOUNDATION (6, ft PROPERTY LINE /5 r ft 1 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 HOJJR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209) 953-7697 SIGNED TITLE COA� dti DATE S � T A U N E N M 2T)EPARTMENT 11SEYONLY Application Accepted B _ _ Date Area Employee ID# . Final Inspection By Date_ 6 ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS�� .11 j. /(Q'Z� JCI�c� �'t�.�•�12L1� •tel/ilit'�fCYYI PE SC Received Che Amount Date Permit/ Invoice# Permit ID# Code INFO ash Remitted Service Request# o QO °t 5 S�0Vlf B 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18