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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)488-3420 NON-REFUNDABLE PERMIT �7 CALL 209 953-7697 FOR INSPECTIONS�+,C EXPIRES 1 YEYEAARfFROM gDATE ISSUED JOB ADDRESS (0 , {S�•t� 'I R I T CITY/ZIP !�/V C'(� ✓' ••�� (1 Z3 1 y CROSS STREET LAJ A.`r.1�—C> APN 19 3-ZZd--Z 0 PARCEL SIZE ��•�'� �• p � O OWNER NAME CltiRt S T/hJ FL-Acx Z PHONE (D O 3 - •1 0 5 7r H OWNER ADDRESS 1 D 7'y I S, PRLIV-S- A4> r�r.rwf CITY/STATE/ZIP FZEAJC,%+ CqM(MP 'jS'2-3 j CONTRACTOR L-N E .��' l�Qr�Mc.•�+ \ PHONE 31001-0-515" CONTRACTOR ADDRESS 4*�-�I W V ACK .5-r- CITY/STATE/ZIP L.O">l C.A q y Z&4 y LICENSE '-: C-42 'J :C-36 OTHER C�y NUMBER ZI S I EXPIRATION DATE T-3L -2-4- WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: . NEW INSTALLATION REPAIR/ADDITION i ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: - RESIDENCE I COMMERCIAL L 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 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 It LENGTH It 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 4 AD VAKENQTICE REQUIRED FOR IPE T/ N -PLEASE CALL(209)952-769 SIGNED TITLE P/COJ yYl(S-(L' DATE T a A N ll DEPARTMENT USE ONLY nEP Application Accepted By L' Date J' Area ' '1 ' Employee ID# Final Inspection By Date ?Uf/ -. SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pi u?np Soil Character: COMMENTS PE SC Received heck# Amount Date Permit/ Invoice# Permit ID# Code INFO By Remitted Service Request# aaa sa3 Is- z- 5 0-1-4� 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18