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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 952DS-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 10C(T ^J• -VAI 41 T L-f'-f• CRY/ZIP -Fz/5- 2/ 9 CROSS STREET �D��n O APN t O I - c>-7o- 3 Q PARCEL SIZE D a {D AC• 9 OWNERNAME ��l`-I�-CV�. 41Dl•-'Pt IBES4 PHONE (�1O OWNER ADDRESS .SPY Y"F_ CRY/STATEalP CONTRACTOR `I ULA 0Alie- G-EOEN✓I(z07JtMr.yV-FA L- PHONE 3Ca03-1S CONTRACTOR ADDRESS 40-7 LA.)• 0AI`--- SIF. CITY/STATE/ZIP Lob 1, C-A R i-2 4p LICENSE 00C-42 00C-36 OTHER CI;U NUMBER Z 1 5 I EXPIRATION DATE 3 V-'LZ WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # F BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: ❑ NEW INSTALLATION D REPAIR/ADDITION El ENGINEER DESIGNED/ALTERNATIVE 1::) REPLACEMENT I.:I OUT-OF-SERVICE SEPTIC SYSTEM 1::1 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 ❑ UFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES (:J 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 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 ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, PAYMENT STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMUM R A QYA NCE NO TICE REQUIR,-DF RINSPECTIONS-PLEA SE CALL -769 RECEIVED SIGNED TITLE PRO- V►1 >2• DATE 3-2 S--2 I MAR 2 9 2021 g SAN JOAQUIN COUNT ENVIRONMENTAL HEALTH DEPARTMD Q � k It 11I v 2 4itW�n I l l l i l l l l I_ I I I I I I I I I I L111111111111111111111111111 / DEPARTMENT US ONLY t1 Application Accepted Bye 'L�� Date �i a Area y q Employee ID# LA Final Inspection By Date ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO s Remitted Service Re .est# 91? sa 3 Is ~ tri LS 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18