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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 f (� CALL 209 953-7697 FOR INSPECTIONS /7 / EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS D (J D /� • 1 �Ct NAP CITY/ZIP Com/C'M e 41 S 41f 11 11 yL v CROSS STREET C��✓ (c%/l�Y/ APN 50 PARCEL SIZE OWNER NAME 17' PHONE O /�/ 7a� A OWNER ADDRESS v ��I /� D`- TY/STATE/ZIP /�C/f�/✓N C�/y�"1�� (� / �i�/ CONTRACTOR ` G/e_5 Q S !7/ C( e/ PHONE CONTRACTOR A DRESS �'` / CITY/STATE/ZIP Oe h/a,/, 4!�4 LICENSE OC-42 IOC-36 OTHER NUMBER EXPIRATION DATE J _-3/ WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: 11 NEW INSTALLATION REPAIR/ADDITION LI ENGINEER DESIG D ALTERNATIVE 11 REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ,RESIDENCE COMMERCIAL OTHER NUMBER OF LIVING UNITS: { NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFGf'4 V CAPACITY �� gal #OF COMPARTMENTS_ ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS i DISTANCE TO NEAREST: WELL 0 ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) CJS LEACH LINES - LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATIONU�ft PROPERTY LINE 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 / WIDTH ft DEPTH IF= / ft DISTANCE TO NEAREST WELLL.S� ft FOUNDATION O 'f 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 HOUR 4DVAiNCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE //Kea.0 AA e /I DATE �� —1/9 n et S E Q /AI N R EPARTMENT IJ SE10 N Y Application Accepted Date Area Employee ID#� Final Inspection By Date ❑ SPE IAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS I 0 r PE SC Received hec Amount Date Permit/ Invoice# Permit ID# Code INFO B ash Remitted Service Request# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18