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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 EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ZZ-'L CITY/ZIP F� CROSS STREET -. kh!NUIl1'A 7 l• APN �10 PARCEL SIZE S /1 Y v OWNER NAMES\�tiy+•I�C�- Of F�PCh�L� ��j(�]� PHONE OWNER ADDRESS (��Il� �ASf,L X —CITY/STATE/ZIP CONTRACTOR � PHONE I—^—\_1OY_"'C\'` CONTRACTOR ADDRESS 40b "CS'(eYV-Cpy &Vi* { /k CITY/STATE/ZIP LICENSE �(C-42 LJ C�-36 OTHER NUMBER �SL` ` EXPIRATION DATE �� J WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinate X Y 7 PERC TEST # BUILDING PERMIT# ' AND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIV REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE I COMMERCIAL IJ OTHER NUMBER OF LIVING UNITS: I NUMBER,,OAF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG C �1 e—. `F " CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFTSTATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TTo NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ FILTER BED WIDTH 1-t.�j ft LENGTH ft DEPTH 41 1 k C-U"$ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ DISPOSAL PONDS WIDTH fl LENGTH ft DEPTH fl 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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)X9153-7697 SIGNED TITLE Ck }ac/L- DATE tv MA I ENTq�r' TMFNT EPARTMENT E NLY �r Application Accepted By Date Area Employee ID# Final Inspection By Date L' SPECIAL PERMIT-Approved by Character of Soil to Depth of fit: Pit/Sump Soil Char cter: COMMENTS 1� �D 0 ►� Iva PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO By Remitted 9 Service Request# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18