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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)95 7697 FOR INSPECTIONS EX�PI IRES 1 YEAR FROM DATE ISSUED JOB ADDRESS _5- CITY/LP I.( /. ef-A -o CROSS STREET_ r Q1/�J11 �In w Q /APN 1 / 7 i R b O U PARCEL SIZE C✓L°- OWNER NAME �'1 Ji'✓IL:s 'f E�Y)L'I JY1 I I1 N V�Y PHONE 6D� �✓+' `I�J- y OWNER ADDRESS `50(in C, CITY/STATE/LP {y 7r CONTRACTOR Y Q / `S PHONE �J �� / 2- CONTRACTOR ADDRESS ! (/' • {,(JL CITYISTATEMP //C�r� �j x �' 3/e UCENSE ufC C-42 (..I-'C-36 OTHER NUMBER ,U EXPIRATION DATE /V� 2- WATER WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIRIADDITION ENGINEER DESIGNED/ALTE�iNNE AT REPLACEMENT rL[N/C OUT-OF-SERVICE SEPTIC SYSTEM J� DESTRUCTION V( r�r Vl KS INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: s NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG i �42✓1 i1 CAPACITY /i h Ge,' gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELLft FOUNDATION_ffl ft PROPERTY LINE 6142 ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH UNES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE 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 UNE ft O SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE ft I HEREBY CERTIFY THAT 1 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. MINIMUW8WIlR ADVJNC&NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 95`3-7697 SIGNED TITLE l i�`H P! < DATE T I J r p NTy ONLY E NT Application Accepted ByDEPARTMENT-USE �� Date O Area 3 Employee ID# iJ Final Inspection By " Date 2CZU I SPECIAL PERMIT-Approved by Character of Soll rto Depth of 3 Ft: P VSump loll Character: COMMENTS 1-6 Ilu/C� b fiGtYl ph+.S �I .Jo :ii,yrK1 �o be rt* -%-f vP 17osS. t°' r -Tw c e h ,off —Sk 6/��'2020 PE Sc Received Chec Amount Date Permit/ Invoice# Permit ID# Code INFO B sh Remitted Service Re est# 09 11:5- 2 Q 5 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18