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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 n'�y EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS -31- .0 JOl/PfI /L/,/ CITY/ZIP �TcN�}IJ�<_ �� v CROSS STREET nW I APN OD 5 3 -20,�3 PARCEL SIZE OWNER NAME «T CY11 t I1 1/t� r�Ji I�ei PHONE OWNER ADDRESS r1� P esS CITY/STATE/ZIP A(I'Wlpy/ CONTRACTOR 11-/Jy4// //41 •c JA PHONE CONTRACTOR ADDRESS ` Y �� I ��X / G !,CITY/STATE/ZIP ✓( - LICENSE ❑� 42 ❑'i C-36 OTHER NUMBER `y�/U TJFXPIRATION DATE 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/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: l NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: L3 SEPTIC TANK TYPE/MFG Ck,3)7 o0 CAPACITY 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) p LEACH LINES i I LEACHING CHAMBERS #OF LINESr' LENGTH OF LINES T �` ft ,\ DISTANCE TO NEAREST WELL I ft FOUNDATION �V ! ft PROPERTY LINE o.0 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 I S ` ft DISTANCE TO NEAREST WELL ft FOUNDATION A710 ft PROPERTY LINE Ly S 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)953-/7697 SIGNED TITLE C.y�IJr'Y!!T t�- DATEH+ y Vj /N E rL'l 11 1 1 1 1 1 1 IE N DEPARTMENT U E ONLY /, /} Application Accepted y �� Date D Area N q% Employee ID# PA Final Inspection By Date �� Z�2v ❑ SPECIAL PERMIT-Approved by Character of Soil to ep of 3 Ft: _ rr Pit/Sump Soil Character: COMMENTS Fo5idure nC line. J�Pr1 a Sgf'✓o Glre,me+ye i- Hw (-Q<f sF 4e o / PE Sc Received Check#/ Amount D to Permit/ Invoice# Permit ID# Code INFO B as Remitted Service Request# `1d1 a 1/5- 2q 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18