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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 MO9)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ��!Y 3qCITY/ZIP U =j m CROSS STREET aAPN O�7-- ?,a - -z 2- PARCEL SIZE d• y 0 v z OWNER NAME PHONE v OWNER ADDRESS / /�J / "�� C '✓' CITY/STATE/ZIP CONTRACTOR �/ C\%�C�V7l / ifio J/V`t �/ / PHONE (-& l 3 b/ CONTRACTOR !ADDRESS �V 2 �J� CITY/STATE/ZIP ,�1_ LICENSE C-42 I-1C-36OTHER NUMBER ✓ >T , EXPIRATION DATE WATER TA/BL\E DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION / REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT + I OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION QL2gny PvOy INSTALLATION WILL SERVE: RESIDENCE El COMMERCIAL El OTHER NU MBERR OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: IV SEPTIC TANK TYPE/MFG v v" `' CAPACITY / `� gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY ` �j 4 gal #OF COMPARTMENTS l 1 DISTANCE TO NEAREST: WELL ft FOUNDATION 1(D + 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 DISTANCE TO NEAREST WELL ft FOUNDATION 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 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY +�� Q19 ft L3 DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH 71-1RO .N�'O`I.._ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE '�F'igo�_�qL — ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH 14%FNT 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. MINIM11M 48 HOUR ADVANCE NOTICE REQUIRED FOR/NSP CTI NS - PLEASE CALL 2 -7697 SIGNED TITLE DATE ollu EPARTMENTU E NLY Q Application Accepted B Date Area C Employee ID#� Final Inspection By Date I 11SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Pi Sump oil Character: COMMENTS PE SC Received h Amount Date Permit/ Invoice# Permit ID# Code INFO B as Remitted Service Request#,01 12 V 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18