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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 �y�CALL 209 953-7697 FOR INSPECTIONS ExPIRESp1 YEAR FROM DATE ISSUED JOB ADDRESS -I V ( E n�1 is^J7 P-0 CITY/ZIP A-C AN%,s.PC) er. 2 H CROSS STREET G pf R I P I TH C'�'^-TZ APN O o-1- 3(o —3 PARCEL SIZEStv • y �/ ^� pC r 0 OWNER NAME f--V I N ! L`�C + PHONE_ �y C) `1'- _f�q c j lA OWNER ADDRESS l/ `' 1 • j A�� CITY/STATE/ZIP frCA CA G`� -L2y CONTRACTOR L--I V E a AX Gt O t Ny(R-d m EN7 11 L PHONE 3(G`7 -D Z 1 CONTRACTOR ADDRESS &4*-1 CITY/STATE/ZIP LOQ I C A LICENSE L.::.0-42 [J'.:C-36 OTHER NUMBER 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 - 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 TYPEIMFG 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 It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH ft LENGTH It 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 It 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. MINIMUMR 4MNCENOTICE E EDFOR l D EAE CALL 209)953-7697 SIGNED TITLE I Q�� ' ��2' DATE � ................................................... ...... ................. s •a` I J o t M I '_ j C 23 7 �H O �5 0- m -------------www-------------------.�._- VED r; DEPARTMENT U 'E ONLY Application Accepted By Date 7 /D 010 Area ��U Employee ID# - �qRU/N CO Final Inspection By Date !v CC' SPECIAL PERMIT-Approved by CTN,.NMF/yT�rY Character of Soil to Depth of 3 Ft:�T-�C Pit/Sump Soil Character: ARTMEM COMMENTS ' .ty.4`l i�OQ�_5�� `\y �l l5 1 `i�l `1 T p"0'% PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO B Remitted S Request# LIdd.�- sd3 Js 111, GK4 AA is 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18