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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 J� CALL 209 953-7697 FOR INSPECTIONS �ExPPIIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS TZQ / 414 -s t- CITY/ZIP47 �oe !� L s� 4 CROSS STREET � APN I" ( 1 2 J PARCEE,rL SIIZZEE /QS OWNER NAME_ ��!J � PHONE-.-;? OWNER ADDRESS(/'��' CITY/STATE/ZIP CONTRACTOR L -If PHONE CONTRACTOR ADDRESS!``0,./ �I CITY/STATE/ZIP"�wi�v'7 L LICENSE ❑I IC -42 ❑1 IC -36 OTHER NUMBER EXPIRATION DA WATER TABLE DEPTH: V GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED /ALTERNATIVE 1 REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM L1 DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL C OTHER 9 1�7 NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG'((�� PACITY gal # OF COMPARTMENTS 0"(— I� LIFT STATION DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft SIZE TYPE OF kMP I ❑UPKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) �Zt ❑ LEACH LINES LEACHING CHAMBERS{{++ # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL � ft`k' ft FOUNDATION Qe• r ft PROPERTY LINE e'+ ft vft FILTER BED y WIDTH I r./ ft LENGTH -5-2- P/- DEPTH 412 - "IP Aa ft �p 0 DISTANCE TO NEAREST WELL ft FOUNDATION `rp ft PROPERTY LINE 5 I ft ❑ MOUNDED WIDTH ft ENGTH 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 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. I1fII/V11Y1 1 SFO V HLJVH/YI.0 lvullk-a rxG; Ulr[CL' rVR IIYJrC1..IIVIYJ - rLCFIJC %-ML.L LUy yA3-/V'Vj SIGNED TITLE - DATE Application Accepted By ate / 7/Q Area Employee ID Final Inspection By QABs eE) Date O t (z t. ( zai N ❑ SPE IAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS:27E::f— .� �i(J ;(� 'jOV 00' t]r-e CUV � Umf S L � U/� 5 —5 - PE SC Received I QhacW Amount Date Permit/ Invoice # Permit ID# Code INFO BV Cash Remitted Service Request # U. -i O c T U C>�® s �C C6 P, c a 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 r0 `� Fi P C C l_ �7 G^ t Ar 1, 00 V F✓—�.`^6 fl Paul) S;1