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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)465-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 39 111, VN1�'1$ _CITY/ZIP S�rC k IL;-✓ tri 2 I CROSS STPEET C N ec-f)Ku, �. APN O `l �._ PARCEL SIZE � z OWNER NAME b'rk-lctija t PHONE OWNER ADDRESS 2 gy—A CITY/STATE/ZIP CONTRACTOR J-- CC�nIgTYZ-l�L'TS1�rJ SFP't'�T-[wL _ PHONE qf(9" rL'Z,g - LiI ?q CONTRACTORADDRESS _()�r_/Z L��?�_c.J t2rZRt oc S'Ir 'Lout CITY/STATE/ZIP AC.9,+V---YWb C+¢ LICENSE L/C-42 C-36 OTHER NUMBER EXPIRATION DATE LP Jb ZU Z- D WATER TABLE DEPTH: �.1%b _ ft GEOGRAPHICAL INFORMATION: Coordinates X _ _ _ Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMEN 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 ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES V LEACHING CHAMBERS :rjvl�1-tra-hO, C-Q zN #OF LINES I LENGTH OF LINES 7 2' ft DISTANCE TO NEAREST WELL 7 ft FOUNDATION ZOO ft PROPERTY LINE 3S 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 UID ft DEPTH 2 S ft DISTANCE TO NEAREST WELL Iib ft FOUNDATION "r ft PROPERTY LINE 5' + 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. IMA11114 AO Un ADVANCE NOTJCE BlEQUIBED 019 10E9QTjQNj2- ELEASE CALL (202)222-02Z SIGNED TITLE i w :G�o t"�" DATE Ofa zaZc' I' AA J E9 O C q � N EPA T U E ONLY Application Accepted Date �7i"� Area Employee ID# � Final Inspection By Date SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pi umo Soil Character: COMMENTS ��—�("1 , (1�(�/iy�F� �[ (��[�) - ,P� rJ lS�- PE SC Receivedheck#/ Amount Permit/ Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18