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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 NON-REFUNDABLE PERMIT I CALL 209 95(3--7697 FOR INSPECTIONS � EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 35-6111, W• E:L ��( N�� D 1 CITY/ZIP lp NA c,y 1_15-304L L -�• -7 a f� Q� R1 CROSS STREET �-`y.�� /� APN f-3 ! 0(0 d -CI�`�'v/ PARCEL SIZE {.� ,`�- p OWNER NAME -��✓t E1- S'�uCT �.-,p /�v✓lH�ONE �J&-4o_ I • W v' OWNER ADDRESS ++ rOOS E- - PSE;D.A�.GI,_0 A-V E. �f2I CITY/STATE/ZIP -Fi2A<- C6 CONTRACTOR r(I/E VFW— '�`"��'^��,��N F'NTIYL PHONE 3�- 0�0 S CONTRACTOR ADDRESS '/"'1 w• 0 Ax- �-• CIN/STATE/ZIP �►OD( ✓�` 1 Z�U LICENSE C-42 '.0-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y X PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION - REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT 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 ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES I LEACHING CHAMBERS #OF LINES LENGTH OF LINES It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It 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 It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 1 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. ,N/IM^UM 2Vq}/{�QU/R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED / -'�- 1 I v` TITLE DATE Z� �-- •LCA 1 1 1 � r 1 n �rmw 15 I — 1 i /02018® KASSON ROADQ�AHC VL//,R p ------------------------------- ------------ - - - - - - Th OE MFiy;Iq jA& a DEPARTMENT SE .LAY/ �RTMFNT Application Accepted ate f Area Employee ID# Final Inspection By Date Z i_I SPEC AL PERMIT-Approved by Character of Soil to pth of 3 Ft: iUSump Soil Character: COMMENTS PE SC Received Amount Date Pe Invoice# Permit ID# Code INFO B Cash mitted Service Reguest# I 2.12•7o e<o 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT