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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 11 '' (/` CALL 209 953-7697 FOR INSPECTIONS / E XPIRES 1GYEAR FROM DATE ISSUED JOB ADDRESS !SI/N Wy/n1A' �'}- CITY/ZIP CC lc.rrw✓If� / J Z C... CROSS STREET AU� Lc.nSS p APN 011 a2 )-01 _ PARCE^LSIIZE OWNER NAME Gk/`4 PAS tPHONE )wy Vz- OWNER ADDRESS I u CITY/STATE/ZIP cprtrl)s p \/ f U G CONTRACTOR 1i 4CS �(� `�•1 W Lj /�L7�,ILS Jtr V I�C/�S•f n L PHONE CONTRACTOR ADDRESS �(A L3 Y I A TU (JZ•9 . �1v14i r iA CITYISTATE/ZIP IN'I e.' 00 S '3DZ LICENSE 'IIq-.1C-42 01IC-36 OTHER NUMBER 1378366 EXPIRATION DATE S/,3//7-Z- , WATER TABLE DEPTH: 13u, 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 \(,A OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION -Y INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: �/(l NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: Ca SEPTIC TANK TYPE/MFG 1•@r0,St D S rl yd-✓ P01V CAPACITY 2-UC gal #OF COMPARTMENTS ❑ GREASETRAP TYPE/MFG I/l CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL v ft FOUNDATION ft PROPERTY LINE -L Z� ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES i I 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 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. MININYM Q HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE GreM Gh DATE ( �I202o AA � HT FO N Vi U 0 M T TY T / DEPARTMENT USE ONLY (1 {� �! Application Accepted By Date Il /11 70do Area � "/q Employee ID# D Final Inspection By U,'VN-� Date til ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS F--,11ule0(--�Grk_ EXiS�{nC S'Wferl on ek1s)-Mr) j"�' Nl'uu 1ZOO otj� SCSPp�iC -601L- unckuCLIkA*., q.s. i2)oi'ZQX PE SC Received Check#Y Amount Date Permit/ Invoice# Permit ID# Code INFO Remitted Service Request# �la0q 11:5, 2Co *3oo 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18