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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 CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS (� �i l• VI L� CITY/ZIP CROSS STREET Cor T6 1 14 a,'p '1/ APIN 1 OJ U O� PARCEL SIZE 0 OWNER NAME 1 ,I ICS(Ji e p Lo t r�� /nGl PHONE K, OWNER ADDRESS JC1 irP CITY/STATE/ZIP CONTRACTOR M, f I�tC1`�`7 SYS K PHONE CONTRACTOR ADDRESS ,QHS k�r�A `>S� CITY/STATE/ZIP LICENSE ❑OC-42 ❑nC-36 OTHER NUMBER� _EXPIRATION DATE 40:4 WATER TABLE DEPTH: 1 C) ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: l *EW INSTALLATION r �I REPAIR/ADDITION GINEER DESIGNED/ALTERNATIVE LI'/REPLACEMENT }O:1ik T F1e�lJ� OUT-OF-SERVICE SEPTIC SYSTEM �STRUCTION �1 CI)", INSTALLATION WILL SERVE: ;FVESIDENCE ❑ COMMERCIAL E, OTHER NUMBER OF LIVING UNITS: If NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: Po-`SEPTIC TANK TYPE/MFF. ��11► CAPACITY l a gal #OF COMPARTMENTS oZ ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL 1,5c,' ft FOUNDATION '11, ft PROPERTY LINE 1In• ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) 3 LENGTH OF LINES .�D I ft LEACH LINES L' LEACHING CHAMBERS #OF LINESc� DISTANCE TO NEAREST WELL It FOUNDATION /S ft PROPERTY LINE �S I 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 7DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft S SUMPS WIDTH a- ( ft LENGTH i� ft DEPTH �d ( ft 1 DISTANCE TO NEAREST WELL Sn' ft FOUNDATION /.S t ft PROPERTY LINE .,,5 ft ❑ 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 1 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 48 H U A CE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL 209953-7697 SIGNED TITLE7�'f-(�Z�=1F�� DATE I) n S A U CT E N zDEPARTMEN USE ONLY Application Accepted B — Date . Area a Employee ID# Final Inspection By Date ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS r -Aee W, j1}.r S S)�-M' I» l< V6r • O;� PC; II, Y! T r Till VZYryell L-6 Ok) c?F 6 ld coia V. Ja"A,00011-77 PE SC Received chgcw Amount Permit/Code INFO B Cash Remitted Date Service Re uest# Invoice# Permit ID# )o 115- 0140 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18