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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 NON-REFUNDABLE PERMIT CALL 2,099)9,553-7697 FOR INSPECTIONS EXPIRES'1 .Y1EAR FROM DATE ISSUED JOB ADDRESS -41-744K+ -2-3644 E. r�y0 z!!JL w �aCIITTY21P L-0 a I G ATO p CROSS STREET pL�A,E �Irs APN Q(P1-040-01 'r - ! PARCEELSIZEE (A`7V) *4C ' o OWNER NAME D�T�� w �CT PHONE CdOC! - 6p 2'Vp.v Ste" OWNER ADDRESS 1-•D• OVY S-O S- CITY/STATE/ZIP C-L-t-hAE0QT; CONTRACTOR L4%IE��QAV- (�•�Ot.�1VTRONMEIv\��- PHONE 3&'1 ` 0319' TT CONTRACTOR ADDRESS 40-7 W• O7\� ST' CITY/STATE/ZIP `-'O�( C—A 4i�ZqV LICENSE L.'C-42 J]:C36 OTHER Py NUMBER d)5" EXPIRATION DATE L/ WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# .- IqjUj TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE 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 It 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 ft DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH R DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH It DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE It 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 R AaVANCE NOTICE RE IRED FOR INSPECTIONS-PLEASE CALL 2 953-7697 SIGNED TITLE PK{T.I Yh�2 DATE a e ,owro• rK n.r.ra V V n — V auw.A wr., ,. - zo JOA Application Accepted By - Date Area Cf P Er _ `•l C1 Final Inspection By Date SPECIAL PERMIT-Approve //a�r Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: �Y MENT COMMENTS 4N PE SC Received Check#/ Amount Permit/Date PermiInvoice# Permit ID# Code INFO B Remitted Service Request# 7C-v 1-2+Z SQQVK431-0 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18