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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)488-3420 NON-REFUNDABLE PERMIT CALL 2009)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS I�S� W• f p L INTT I ry CITY/ZIP 7T�R11-f4 C-4 91'U04 ` y CROSSSTREET ,�yyy r'• APIN 2• �' « OT PARCELSIZE 3�'�„`• p OWNER NAME �1C"r'EL •SI t-VA PHONE Oa4-93oG` m � OWNER ADDRESS 2£rya M!•iN C�5 CITY/STATE/ZIP • •""'� C A +0� CONTRACTOR I-1 JE 0AV- GEo FAQ,.>V t(La�.�►'hE'ev i IPYL. PHONE 3V`i-C)"3-7 S A CONTRACTOR ADDRESS �C'� 1 w p O K ST CITY/STATE/ZIP L151>I CA 9 S 14 O LICENSE E' C-42 DiC-36 OTHER epi G' NUMBER 2-I EXPIRATION DATE '4 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 I DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL _ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPEIMFG 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 It 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 ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It 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 91 QUIR AQVAIVCE NOTICE REQUIRED FOR INSPECTIONS- LE E CALL(209)953-769 SIGNED TITLE P�o'�• ►�GQ• DATE C1•9`ZO FO N AHC ?0?� Fp,�TM�N�, FNT DEPARTMENT! EONLY G Application Accepted L Date q/1 D 0ny Area s / Employee ID# DA Final Inspection By Date 474 1 r SPECIAL PERMIT-Approved by Character of Soil toD pth of 3 Ft: PiVSump Soil Charade COMMENTS 41'—C.O 'b r1 ` Q" b i 02_G /f PE SC Received hec Amount Date PermiV Invoice# Permit ID# Code INFO sh Remitted Service Request# y as 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18