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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 CA L 209 53-7697 FOR! SPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS V 4 CITY/ZIP L r CROSS STREET t �d^^ ^�✓ APNj 1 61 PARCETL SIZE r Z' OWNER NAME �N^} � A/'N`�/ PHON4Z �+ ) 72? OWNER ADDRESS ^ L �"' CITY/STATE/ZIP tom-- L2!<-r-?/r CONTRACTOR / 4Z)&eA�C�,17��'�- ~ Je�tJ C PHONE Z d �1 /7 J — "7.l _? CONTRACTOR ADDRESS /" / ��/"�� (�- CITY/STATE/ZIP LICENSE LI-C-42 L. C-36 OTHER NUMBER7/-T 1�'IQC EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y L PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION d // REPAIR/ADDITION ENGINEER DESIGNE /A TERN VE & REPLACEMENT �'7�l` OUT-OF-SERVICE SEPTIC SYSTEM 411, DESTRUCTION INSTALLATION WILL SERVE: !i RESIDENCE I; COMMERCIAL L OTHER NUMBER OF LIVING UNITS: -- // NUMBER'OFF BEDROOMS: NUMBER OF EMPLOYEES: El SEPTICTANK TYPE/MFG Go C!� CAPACITY / ®d gal #OF COMPARTMENTS �Z ❑ 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 DISTANCE TO NEAREST WELL It 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 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 R DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH R 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTION4-PLEASE CALL(209)953-7697 SIGNED -G� TITLE DATE X020 QU�N C T pCOU MF,�,r B PARTME T ENLY Application Accepted Date Area Employee ID# Final Inspection By Date l_ SPE AL PERMIT-Approved by Character of Soil to Depth of 3 Ft: USump Soil Character: COMMENTS�,-; Y cc „y*n/7 0 t OS Con G PE Sc Received hec Amount a Permit Invoice# Permit ID# Code INFO ash Remitted Service Re uest# SRO S 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18