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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 209 953-7697 FOR INSPECTIONS �" L EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 3 U �i l L")✓( e— tT--.e— /a CITY/ZIP &IGt 1Cr4 ':: C-3 ' CROSS STREET I A YJ46 r y APN ^� 7 �� PARCEL SIZE z OWNER NAME�n/,� �,/{�� I^yl 4 PHONE e OWNER ADDRESS b/ C'S/�\/ �.,[, CITY/STATE/ZIPIZ,-- y CONTRACTOR I`I'LL ,��'iZ(C JY' (^ PHONE u, >�'^��` CONTRACTOR ADDRESS �� 7L � �O J V CITY/STATE/ZIP'/{' 'G/74-4-,6 t e p} l C� jS3 LICENSE ❑ C-42 ❑I C-36 OTHER �- NUMBER n t7� ( EXPIRATION DATE WATER TABLE DEPTH: / U U ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# l�1 r7L1,5 3 LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: l NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG CAPACITY j � 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 LEACHING CHAMBERS #OF LINES�� LENGTH OF LINES ( ft DISTANCE TO NEAREST WELL O ft FOUNDATION d I ft PROPERTY LINE In I 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 0--'SEEPAGE PITS NUMBER 3 WIDTH It ft DEPTH 2 S , ft DISTANCE TO NEAREST WELL— A i ft FOUNDATION L(b' ft PROPERTY LINE b 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 HQU4j ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209) 953-7697 SIGNED TITLEL (1Cts T DATE tea( J6, NJOQI VIM RT E T EPARTMENT US ONLY d Application Accepted By Date O Area Employee ID#4n Final Inspection By 71� Date C ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth dfr-3 Ft: it/stimp Soil Character: COMMENTS-jj�CQ--0 PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO B s Remitteol eryice a uest# l ue 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18