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Y 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 �_o -7 d Llt�� x ✓� CITY/ZIP t��</��iri Ca✓t✓� i Gy� •Sd3 1 .n 'J M CROSS STREET ��1G� ��Y1 F APN 1 PARCEL SIZE y • �� M qC/ G c OWNERNAME Vt �fI /�AC` C��(�� 11( 6�t� -4 �'SR h�fic I`{r-L PHONE L ZJ "L4 D7� OWNER ADDRESS /X3 r.c�/ CITY/STATE/ZIP �} CONTRACTOR I'M r ' I ��C}� Ak� Z�f�r! �Y� S�`� PHONE 1 CONTRACTOR ADDRESS PO 1 X �� CITY/STATE/ZIP / I 4-w,-&4- LICENSE ❑' C-42 Eli,C-36 OTHER NUMBER EXPIRATION DATE_ 2::Oan WATER TABLE DEPTH:?� 7n ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT## LAND USE APPLICATION## TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION 7INSTALLATION WILL SERVE: L? RESIDENCE ❑ COMMERCIAL ElOTHER NUMBER OF LIVING UNITS: I 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 ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft FILTER BED WIDTH Inn ft LENGTH L4 ft DEPTH (g'I ft DISTANCE TO NEAREST WELL j 'J:51 ft FOUNDATION In r ft PROPERTY LINE IS r 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 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 48 HOUR ALWANf.LN0T10E REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE1"c e,{5 DATE ��5�.} SAN O Q IN O N L • EPA RTMENTUS ONLY Application Accepted Date Z-� Area Employee ID# Final Inspection By Date ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS :nf�:", (ZIVP!r MLAIC!YJ PE Sc Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO B Qash Remi ed Service Request# o u " 0 5 � 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18