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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,2.. e CITY/ZIP S C- Cel 5 d �_!I y/� f J M CROSS STREET /X (p APN Q&7 I"'► O 1 O PARCEL SIZE OWNER NAME a/y/` ,(�L �yo e,� _P/HONE aaq �\ OWNERADDRESS19 /" �� C��"� � CITY/STATE/ZIP 7'77 �� A� CONTRACTOR S-r2 N G p e e PHONE i CONTRACTOR ADDRESS /V �� as a w ✓ e CITY/STATE/ZIP LICENSE 11C-42 ❑I 'C-36 OTHER-Cd 7 NUMBER k&l �//j EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y C PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE I REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION 5Z I rL JU 114 INSTALLATION WILL SERVE: C RESIDENCE ❑ COMMERCIAL E 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 ILEACHING 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 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 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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-769/7 SIGNED TITLE VC-e-�✓t 15' DATE 0;k 6,,:� q V r T DEPARTMENTUSE ONLY 117/ Application Accepted y �.� ` C Date 7 ?e ,;,,aC Area I� q Employee ID# Final Inspection By Date C-3 '1D L SPECIAL PERMIT-Approved by Character of Soil to Depth of Ft: Pit/Sump Soil Character: COMMENTS Pro os u;1Jrvr y,w*h ( hwsE'. PC'IMI? no J l5 r7 sb"is' .ale 1 c"ti F;elcl /h 6r/e'�. I,JI- wtiv be o'le et >J»el: C)Wr'Pr tD If 'Vk%"k is +Psek4 ernCI 5 0J Jn5I2e67OyQ+�� wrof ko 4ca ow 4 -Frr��,��a.,� '� vc� GIS. a-Cro PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO B Cash Remitted Service Request# �laa 07-S_ V S a 1s 13t r� 0 �� r 42-015 Sr �� r 1-ii / - I J ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/16