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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 PERM IT 1 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED ^ JOB ADDRESS 1 ID - C 11�Qkstffin lZli CITY/ZIP TC CA C CROSS STREET CJ1RtSNtt {�y� APN Ot J a 09 39•+ PARCEL SIZE _�v b (� f�,Q I� d OWNER NAME �)U�V CT T Q'r Aa�O PHO.NEE < 7 OWNER ADDRESS �tJ OX �� CITY/STATEIZIP �I y CONTRACTOR Sq�.1V Z Ciro�4LC�1+rn INC- PHONE I?Cr7 /l �/�� S Q �J CONTRACTOR ADDRESS _Fq-ifI '.iIL� �D C CITYISTATEIZIP _TtYgC� 11-�7�J 1S3D�1 LICENSE LIC-42 ❑IJC-36 OTHER NUMBER ✓�' I EXPIRATION DATE Z WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTER ATIVE REPLACEMENT 37(Q"F-r LI j tl OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION L INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMER�(JAL Ef OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: > NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG (� CAPACITY O`�t/ gal #OF COMPARTMENTS C GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKGTXPLAO ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) 4L, - T,;? LEACH LINES [j LEACHING CHAMBERS L7T� #o LINES 0 LENGTH OF LINES DISTANCE TO NEAREST WELL� ft FOUNDATION 10fi ft PROPERTY LINE S 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 ❑ 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. MINJAWMA8 HOUR ADVANCE NOTICE REQUIRED FOR INSP CT/ONS - PLEASE CALL 209 953-76977 SIGNED TITLE 4�°I DATE '�, 2 L®�,\ U 5 J A J A 0 N UI C � NA E T DEPARTMEN_T S ONLY S Application Accepted B �"— Date_ 7/0lTZ� Area Gy Employee ID# Jl� Final Inspection By Date 06(p2 f'202D SPECIAL PERMIT-Approved by Character of Soil to Dth of 3 Ft: Pit/Sump Soil Character: OMM NTS F�11u>e ,J )11 ie/ MAv be qdd)','A 5k qCd1i0oAA1 heel in thp f C t 'nr © v%. ' PE SC Received Check#/ Amount Permit/ Code INFO By Cash Remitted Date Service Request# Invoice# Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18