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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 �A�pCALL 20p9,9553-7697FOR INSPECTIONS EXPIRE rS 1 YEAR FROM DATE ISSUED JOB ADDRESS 3omli �• EDI�AR;pS I `ve.- —CITY/ZIP OK��AL-G -i CROSS STREET C-OM ET A APN 2-b1 ZCtO Z PARCEL SIZE Z' At• > 0 �y0 OWNER NAME —IN�A.S Cy/� PHONE te-1 Cl —Cf 6 2-1 OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR L Iy I:. 0 A I4 &-t— `NO"Ah"CAJ� PHONE 3(R 9 - 03-7'I c. �/, CONTRACTOR ADDRESS 4D7 W K S • OAI • CITY/STATE/ZIP G0t>t..GI A �Z-{Z) / LICENSE ._1� C-42 CIC� ]�6 OTHER I l� NUMBER o(�s 1 EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: - RESIDENCE J COMMERCIAL L OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG 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) ❑ LEACH LINES 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 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 1 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 41h HOUR ADVAKE NOTICE RE IRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED TITLE PO1 4416_2• DATE Nr 17 FO 20 C DEPARTMENTIJS ONLY ;lA�� T Application Accepted By Date oYzU Area �� (� Employee ID# Final Inspection By "Y~w �� Date f', SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS .O2-90' /�e.Yc/!•r�ty +�1-e' 17�+t�O, �{IwGI�.✓ tL�QtL /7�J.cI• Stb PE SC Received hec Amount Date Permit/ Invoice# PermitlD# Code INFO B Cash Remitted Service a uest# 10� s 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18