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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 4040 W• KAj&I0-0*j /LD • CITY/ZIP L-at' gS7•4-'L � CROSSSTREET N`QQM L�y APN VZ�O -2-1 /PARCE`LSIZE `• I''- > A, OWNER NAME -�1"''_ _I /'�7�r�L(J� PHONE OWNER ADDRESS 5-4r, g510 (merry ( tove C I r CITY/STATE/ZIP 5��.rar►'�tn�° 4 S�'2�1 CONTRACTOR LNC 0^'l- CrtOC,A"vlA0NMC r� PHONE 30911`0-5 q CONTRACTOR ADDRESS &40-) W• V[h- ST• CITY/STATE/ZIP LOO I i C- 1 T' LICENSE 1-1 C-42 1-j. C-36 OTHER C.e6- NUMBER -Zl S( EXPIRATION DATE T `3 -A-2- WATER ZWATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # l 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: 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 It 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 It FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH It 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 It DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It 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 R A V E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 2 7 SIGNED TITLE r J ' m G 2 DATE lk SFp F I �0 O �Fti'T / DEPARTMEN U EONLY Q Application Accepted By, ��v Date O Area I Employee ID#_A Final Inspection By 7 Dated ❑ SPECIAL PERMIT-Approved by Character of Soil t pth of 3 Pi ump Soil Character: COMMENTS I.t�c D DS i jy� y D 'a120Y -tet int C PE SC Received Che Amount ate Permit/ Invoice# Permit ID# Code INFO Bv, as Remitted Service Request# ��aaa s�3 ►sa sv S 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18