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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 CITY/ZIP CROSSSTREET rT/��J/�--Or{ /`T/ /� / APNf 0& 00/�V,—0 S PARCEELSIZE]A(AC�c�S o OWNER NAME N Crl (.�i/eY )CS��i -CCT &1 1 HONE(1-010 S-0 1q5 OWNER ADDRESS �2 2?I ' `�Dy � C CITY/STATE/ZIP ��G(�t Ci'9 ` �� N CONTRACTOR 60" ` /z 62f�H PHONE v' CONTRACTOR ADDRESS t7S NK "fir CITY/STATE/ZIP /"� 5'ZVb LICENSE :1C-42 �' C-36 OTHER NUMBERPFf4 7RA ON DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION I REPAIRIADDmON ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: 7 RESIDENCE ] COMMERCIAL 11 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 �J DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft \v^) ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft i ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft O 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. MINIMUM MHOUR ADVANCE NOTICE REQUIRED FOR IN E SIGNED TITLE Y w—1 4 DATE r 7- S CF�V�O FP 2 SgN�o 12419 y� q OAj� M C IV�, gRTMFNT RTMENT USE ONLY / ' Application Accepted Date //11 2T ZC Area mployee ID# Final Inspection By Date / J : SP AL PERMIT-Approved by Character of Soil to Depth of 3 Ft: PRISump Soil Character: COMMENTS �J - -:3 v K f l i 3 PE SC Received Che Amount to PermiU Invoice# Permit ID# Code INFO B ash Re i d Service Re uest# ZZ ti� 7 0 ti ©` 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/16