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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 -r CALL 209 953-7697 FOR INSPECTIONS EXPQIRES 1 YEAR FROM DATE ISSUED Z N JOB ADDRESS 19-1-91 • CCITY/ZIP I•-OP 1 `1 CROSS STREET 30 N I C L1`/ APN D S 1 -0 LG-ZZ PARCEL SIZE O•T4 AC' p v OWNERNAME CIO N-qD /'Fo#Mr,S /NC PHON-E__22? -993. G OWNER ADDRESS 3XI 1 IfFr. DONE`S a _j -pie_• _ CRY/STATE/ZIP GMC* 1 N C/A qS.•1 / CONTRACTOR I-IV OPrV- C C��VIr�[JNW�F.N1 �Z- PHONE ✓�!- C'3-IS p CONTRACTOR ADDRESS �k-7 IN. 0� sr' CITY/STATE/ZIP L.01D 1 C 11 q� LICENSE I- C42 l I'.'.C-36 OTHER ct b- NUMBER 7-1 I ERPIRATION DATE 4-30 -1-2- WATER -30 -22WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y J" 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 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 0 PKG TX PLANT O 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 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 ft DEPTH ft DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH It 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 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. MINIM V N E NOTICE REQUIRED FOR INSPECTIONS EAE CALL 2953-769 SIGNED TITLE I/Zft-I • DATE 1-30-216 1'R�I�NT ��VFO H Z 20?0 roc/ DEPARTMENT.0 E ONLY p HTq��' c.Cy Application Accepted By r_ � Date 0 d Ov`a Area `I � Employee ID#�� F /, Final Inspection By SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS t,:iLAA PE Sc Received Amount Date Permit/ Invoice# PermitID# Code INFO B Cash Remitted Service Request# yaaa 3 Z 1s2 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18