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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'llbal6 �j ��>�>G;� BUZ CITYIZIPP L� CROSS STREET >}O,�IeS APN_�'�1 �� / PARCELSIZE 17 OWNER NAME /►/G J ��P 3 A M bt 1 ,44sc4 r,'5 PHONE / OWNER ADDRESS I k:) Pe I/� s� r CITY/STATE/ZIP Aci -opo ^t��y CONTRACTOR l�s��-f7G f�H�IC;� �/J�ir► PHONE CONTRACTOR CONTRACTOR ADDRESS lj,� CITY/STATE/ZIP LICENSE ❑ 1 C-42 ❑ i C-36 OTHER NUMBER 7�WVS_EXPIRATION DATE WATER TABLE DEPTH: % 0 ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # d00 aWffLAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION INSTALLATION WILL SERVE: 39F RESIDENCE ❑ COMMERCIAL l ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: / NUMBER OF EMPLOYEES: j;1— SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG Y";IG CAPACITY f GU gal # OF COMPARTMENTS TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS Amount Remitted # OF LINES ;?- LENGTH OF LINES S-� ft Invoice # DISTANCE TO NEAREST WELL J66 ft FOUNDATION /00' 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 Y3" ft DEPTH }� ft DISTANCE TO NEAREST WELL ft FOUNDATION �'S-U ft PROPERTY LINE 1l1 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. IVIIIVIIV/U/VI 40 f7VUry HL>VA41Vl.0 /vl>1ILIC fSC U11[CLJ rvr[ 11VJrc%.11vlvo cv: SIGNED_ e TITLE /.��ir�/.2�/�e - DATE DEPARTMENT SE ONLY 7�� Application Accepted By LI Date / a Area ci Employee ID# D Final Inspection By r� Date W ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS e cad E )e>- e 0b, Z PE Code SC INFO Received B4 Check#/ ash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# H31 0 1� 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 C n