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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 t1 ]Cm21P CROSS STREET L'LJGC 1//-/�O.S /F/� APNy S,"d 0+I� PARCEL SIZE OWNER NAME %M• i/7 �'At 0^, PHO/NC�—�K��6�� Jj� IpYlh: C n OWNER ADDRESS �T h�"I+ CITY/STATE/�ZIIP CONTRACTOR��(L{�L�lf&Y1NP }:f- PHONE CONTRACTOR ADDRESS �72..Y E /�� 2-ry CITYISTATE/ZIP �Y-,�Orr IiR�U/✓ G/L ✓I�i�-�./ LICENSE [1::C42 ❑❑C•38 OTHER NUMBER > EXPIRATIONDATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: U NEW INSTALLATION REPAIR/AODITION U ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: �'YRESIDENCE ❑ COMMERCIALdl fl--' {�y❑❑ OTHER NUMBER OF LIVING UNITS: p NUMBER OF BEDROOMS: C' LP I>71,NUMBER OF EMPLOYEES: SEPTIC TANK TYPEIMFG / �/ CAPACITY /I5 O D gal Y OF COMPARTMENTS '-]i ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL TUU i-Z It FOUNDATION ft PROPERTY LINE ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft A..! DISTANCE TO NEAREST WELLIft FOUNDATION ft PROPERTY LINE ft /�• FILTER BED WIDTH�ft LENGTH Y 19 ' It DEPTH y2, -it - v� DISTANCE TO NEAREST WELL Z�2a/-L ft FOUNDATION ',2 It PROPERTY LINE�C ��' ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH R DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ DISPOSALPONDS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE It I I ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It 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. MINI"48 HQUa 4t)VMrF NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL(209)953-7697 SIGNED TITLE Cy - DATE 22'20 I 1 I RF YMFNT CF�V�p I X'01111 OR 222020 N.R0NJOAQMFCOUNTY H DEAgRTMENtV T A T tENTU Y Application Accepted By � /�' — Date �"k �;'"% Area �� Employee ID# 5 K Final Inspection By Date W 0 SPECIAL PERMIT•Approved by Character of cnil-J n—ti,of 1 pt. PIVSump Soil Character: COMMENT; L It N d h (e ., i t rP 'i iY. e o f fuc r d l�-�e � PE SC Received Check#/ Amount Permit/ Code INFO Cash Remitted Date Service Request# Invoice# Permit ID# I5 4300 22 iQ 12.01 _ n ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4111n8 Scanned with CamScanner