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OF ; ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT (� CALL(209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS j O 3 31 N ` L �'�// / � CITY/ZIP G t f�� J�! 2- Z CROSS STREET L� � _ m C\/e. e d APN 19 d D 3 CIC4 PARCEL SIZE I' I�` 0 •� ` Ca J Q {� z OWNER NAME ��( U C.(� -�/ ffl e-S op P�HO/N'[Jao I(/ [ 0 -( q OWNER ADDRESS ?, �(Z Los 6Ly o,S (wt- CITY/STATE/ZIP (N r, CONTRACTOR 00 n61- PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑'.:C-42 01 IC-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I I ENGINEER DESIGNED(ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM )( DESTRUCTION Le-111! INSTALLATION WILL SERVE: C RESIDENCE ❑ COMMERCIAL C 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 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE V 'Y ❑ FILTER BED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE L. ❑ MOUNDED WIDTH ft LENGTH ft DEPTH N✓O DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN /RO CO ❑ SUMPS WIDTH ft LENGTH ft DEPTH '�� ~�YrA� ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE Nt ❑ 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 I HEREBY CERTIFY THAT I HAVE PREPA ED 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. MI MU 48 HOUR A9VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNE TITLE DATE !� , DEPARTMENT USE ONLY C� //�� Application Accepted By � G�` Date /0�,?%.ao Area / Employee ID# D4 Final Inspection By Date \` Z \'t1z>"kzxo G SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS�NO e,►'Istl Jsi' r� c�P.?9cP o7-I /o Spplic �c!)9�l fC?IY/c-iin �roir �//� � "" PE SC TReceived Check#/ Amount Permit/Code INFO Cash Remitted Date Service Re gest# Invoice# Permit ID# o7S- t ElsaWSW 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18