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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 ADDRESS -T ,90 CITY/ZIP ACX 7O3.T04 v► nn CROSS STREET L'/M O 2 D APN ;;75-,P-1&,9-13 PARCEL SIZE 7• l 3 C d OWNER NAME 4120WA L 991(0 CA 6 L-4 -TY 57- PHONE OWNER ADDRESS t 457 WEST DuR HA m rEFRELy IZ D CITY/STATE/ZIP Tom' GA �l S '04 CONTRACTOR CHC-5NEx e4ftis LT/nl( _ PHONE �D f 4-);-- IG5,2 CONTRACTOR ADDRESS P.D .> K 3 711 CITY/STATE/ZIP T/k$LDL Vi CA q,5-36 l LICENSE ❑0C-42 ❑0C-36 OTHER i2Cc NUMBER 75479 EXPIRATION DATEG O ZULO WAT R TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: ❑ NEW INSTALLATION Cl REPAIR/ADDITION D ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT F 1 OUT-OF-SERVICE SEPTIC SYSTEM 1 DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ 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 El LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) 0 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 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ MOUNDED WIDTH ft LENGTH ft DEPTH S'C � DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH JCA ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI RO/� ft Or Lam. DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH EpgRTa 14 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 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. MI (JM 48 R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE C/l�/L�/VL/�VEE,f� DATE 0 0 r1Z T-R 5 EPARTMENT USED LY Application AcceptPpy Date Area Employee ID# Final Inspection ByLFAA Date ❑ SPECIA PERMIT-Approved by Character of Soil toh of 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received —Check#N Amount Date Permit/ Invoice# Permit ID# Code INFO B emitted Service Request# _ Y 35sL• SROo 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18