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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 S Jr Q (+ CITY/ZIP 1 CROSS STREET ✓e,o y APN PARCEL SIZE o OWNER NAME L1 d✓ / PHONE v OWNER ADDRESS (///JL CITYISTATE/ZIP CONTRACTOR /'wkN 14/40 /`/0 rl�////I'�. PHONE CONTRACTOR ADDRESS l�l {G'J tL�� ^� �/ CITYISTATE/ZIP LICENSE El IX-42 ❑1 iC-36 OTHER NUMBER '75��7� EXPIRATION DATE WATER TABLE//``DEPTH: j} V ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION IENGINEER DESIGNED/ALTERNATIVE 1 REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM )( DESTRUCTION T G.11 INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMB/ER OF BEDROOMS: .' NUMBER OF EMPLOYEES: 1,16 SEPTIC TANK TYPE/MFG zleme ,P z/'i CAPACITY l/Y oQ gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS i DISTANCE TO NEAREST: WELL l ft FOUNDATION It PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS #OF LINES /3 / LENGTH OF LwEs `70� I ft DISTANCE TO NEAREST WELL ��` ft FOUNDATION Cao , ft PROPERTY LINE (J! l 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 /y/ / ft DEPTH I/ / /, ft DISTANCE TO NEAREST WELL BOO ' ft FOUNDATION �D ft PROPERTY LINE ce ' It ❑ 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. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-76697 SIGNED TITLE �(/t? �il��✓ DATE 7- P-,520 Q I Veil In S DEPARTMENT USE ONLYC� HFdENVIRQ C Application Accepted B —�G�� Dated .2Od O Area / E'rr��T1 IV tf Final Inspection By Date TLk' �:�'�: L SPECIAL PERMIT-Approved by Character of Soil to D pt f 3 Ft: )Pit/Sump Soil Character: / �ayp� COMMENTS FPO)e-Gr(yV_� S N� • Pr a+ cz��G' sr/incj9. �XIj*11>7� 1'7on— r' con (pei ; 7S 1o1 . Nc,,j sYSf�wI PE SC Received hec Amount Date Permit/ Invoice# Permit ID# Code INFO By ash Remitted Service Request# �- 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18