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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 -is 2Tb41`'r'N.III) 1/1 C_LAL �.T CITY/ZIP z CROSS STREET L�c�:l�/J/ZX"�iC /!�L APN o 13x6017 PARCEL SIZE 7S p ' C OWNER NAME z-C-M(i11' r0'ee( 3 VPIO%11iG. PHONE OWNER ADDRESS SriJ we-/ CITY/STATE/ZIP CONTRACTOR CG.I X12✓► L !/'� =C�//V PHONE CONTRACTOR ADDRESS 7 C ✓' " �� CITY/STATE/ZIP LICENSE ❑p!�:42 ❑LIC-36 OTHER NUMBER `7�/L/Y SEXPIRATION DATE l WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION IJ ENGINEER DESIGNED/ALTERNATIVE I.I REPLACEMENT _ OUT-OF-SERVICE SEPTIC SYSTEM i:1 DESTRUCTION INSTALLATION WILL SERVE: X RESIDENCE ❑ COMMERC1 ❑ OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG Citi/JN-�, 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 �SZ` ft FOUNDATION ��' ft PROPERTY LINE ��O 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 y ft DEPTH _ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE �L� 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS//-PLEASE CALL 209)95//3-7//697 SIGNED ��- TITLE t /Y '� DATE I,4/F 'k f, J.1 N A .NI 'A L EiARTMEN 1 DEPARTMENT USE ONLY Application Accepted By c' ZI — Date Area oh� Employee ID# bAfP4lui Final Inspection By Date � I rh�I z"o SPECIAL PERMIT-Approved by 6,` Pyr G Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTSolu;e, Ori ollbllc ,4e, es rZo3Fp,"S�IT�iT-;rocL'f- &r fu( i t� �, e Y� insoFcY�r �P��sore _rA2As c�Gs c��►I�P�' �0 6r inslz;l�i '. PE SC Recei ed Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFOCash Remitted Service Request# u)13 115 ` 30 W I . I '-0J 4-*ch line �/ /! be U✓/Clrr 4 w,al,"d. fZoa� ;rt�� J}r�7� d�► 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18