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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186E E.HAmTON AvE1/11E-STDCKTON CA95205-(209)4683120 Nom-REFUNDABLE PERMfT CALL 209 953-7697 FOR INSPECTIONS ExPIREs 1 YEAR FROM DATE ISSUED JOB ADDRESS/ t09 - Qp7Yf2)P �7LA LL, ?5 2 u Lr CROSS STREET H ,J AP14 r�y�nr O O 30� ^r--PARCEL S=z23.73 OWNER NAPE 01ri J \1C1I Pff A(� DINNER ADDRESS' 13}/.�V-1 9 . LQmrn�1ylP.yC.5'`.k0 QTY/STATEMP Ce CONTRACTOR �'/�'t 5 C1r—&0C �✓^e•--'8 V iLI o ,' RHONE - y-5 z �( ?f CONTRACTOR ADDRESS 4. i►I �+��j �J y 'f't-�y U C.ISTATE/LP 1 1 1 D AL J 1 1J (A LICENSE C-42 C36 OTHER I"T NUMBER 1 1 3 D zLi ExP1RATKIN DATE WATER TABLE DEPTH: JO ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST i BUILDING PERMR# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION Q Iii REPAVRIADOInoN ENGINEER DESIGNED/ALTERNATIVE RE PLAC9IBIT OUT-OF-SERVICE SEPTI:SYSTEM DESTRUCTION INSTALLATION WILL SERVE: H Belo CE COMMERCIAL OTHER NUMBER OF LINING UNITS: i NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: [` n Elm SEPTIC TANK TYPEIMFG C CAPACITY I OnC gal #OFCOMPARTMENTS G ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS 00+❑ DISTANCE TO NEAREST: WELL': It FOUNDATION ft PROPERTY LINE 100+- LJ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT 0 SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS #OF LINEs LENGTH OF LINES DISTANCE TO NEAREST WELL ft FOUNDATION� ft PROPERTY LINE `� ft ❑ FILTER BED WOTR It LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE It ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY UNE ft ❑ SUMPS WIDTH ft LENGTH It DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY UNE ft ❑ DISPOSAL PONDS mom ft LENGTH It DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE ft ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH It DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft I HEREBY CERTIFY THATI 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. NOTICE REQUIRED FOR INS�&CHQJVS-PLE&U.CALL(2D-9)953-7697 I SIGNED 1 TITLE / I. DATE '/ i PAYMENT DECEIVE® R 0 2020 � DEPARTM ONL Application Accepted By �1zGL Date 0,10 Area Employee ID# D/L Final Inspection By A. Date � SPECIAL PERMIT-Approved by 'SAN JOAQUIN COUNTY Character of Soil to Depth of 3 PI= PttlStonp SOIL Character. ENVIRONMENTAL EALTH DEPARTMENT COMMENTS ' r o sfeP, j of S � Yri o V -"' or o " V In �Lu PE Sc '11. Code INFO fled Cas Ramified Dale Se�e�Request # Invoice# Permit ID# 11 S" 300 7 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18