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UNSITE 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 LJAATTE¢ISSUED 4e2JOB ADDRESS CITY/ZIP "' ✓-� CROSS STREET/�/ APN (/JlJ -� S� ^�� PARCEL SIZE OWNER NAME � ".�A� 4I GC/ z�i- /< PHONE OWNER ADDRESS j_ 0 ' I/ r3 CONTRACTOR CONTRACTOR ADDRESS Y �Plv va c "000 J^_ LICENSE ❑0C-42 11❑C-36 OTHER NUMBER�� S �f� fY/STATE/ZI/P [I�G-(/^Q({,�. PHONE iZ d 17 3 CITY/STATE/ZIP _(/�7dLi EXPIRATION DATE ��3C3 T� WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: COOrdlnateS X Y ❑ PERC TEST # BUILDING PERMIT## LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION 0 REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE ❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL El OTHER NUMBER OF LIVING UNITS: NUMBER OF B DROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK Ll GREASE TRAP ❑ LIFT STATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL SIZE TYPE OF PUMP ❑ LEACH LINES ❑ LEACHING CHAMBERSia CAPACITY _ CAPACITY ft FOUNDATION PKG TX PLANT ❑ # OF LINES gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LENGTH OF LINES DISTANCE TO NEAREST WELL ft FOUNDATION PROPERTY LINE ft FILTER BED WIDTH Z ft LENGTH /O� ft DEPTH ft DISTANCE TO NEAREST WELL �o ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ® SUMPS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE HEREBY CERTIFY THAT 1 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. IrI1IY11YIVIn V IIVVII YJ Vy,.L'lL hc /96f-lly LrL Iyl/l!(yllTu I-IAn IC tlJrL_V II4J rLCl, JIV� FiJC .hpLL ILV: Application Accepted Final Inspection By CharartPr of Soil to ❑ F'AKTMEN7 SE NL T?p� B Date Area V � """ employee ID# Date ❑ SPE AL PERMIT -(Approved by enth of 3 Ft[ it/Smmn Snil Chnmrtcr% ft ft , ft ft ft ft ft ft ft ft PE SC Receiv Check#/ Amount Date Permit/ Invoice # Permit ID# Code INFO h Remitted Service Re uest # 42-01 ONSITE WASTEWATER TRTMNT SYST 4/14/18 HEREBY CERTIFY THAT 1 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. IrI1IY11YIVIn V IIVVII YJ Vy,.L'lL hc /96f-lly LrL Iyl/l!(yllTu I-IAn IC tlJrL_V II4J rLCl, JIV� FiJC .hpLL ILV: Application Accepted Final Inspection By CharartPr of Soil to ❑ F'AKTMEN7 SE NL T?p� B Date Area V � """ employee ID# Date ❑ SPE AL PERMIT -(Approved by enth of 3 Ft[ it/Smmn Snil Chnmrtcr% ft ft , ft ft ft ft ft ft ft ft PE SC Receiv Check#/ Amount Date Permit/ Invoice # Permit ID# Code INFO h Remitted Service Re uest # 42-01 ONSITE WASTEWATER TRTMNT SYST 4/14/18 IrI1IY11YIVIn V IIVVII YJ Vy,.L'lL hc /96f-lly LrL Iyl/l!(yllTu I-IAn IC tlJrL_V II4J rLCl, JIV� FiJC .hpLL ILV: Application Accepted Final Inspection By CharartPr of Soil to ❑ F'AKTMEN7 SE NL T?p� B Date Area V � """ employee ID# Date ❑ SPE AL PERMIT -(Approved by enth of 3 Ft[ it/Smmn Snil Chnmrtcr% ft ft , ft ft ft ft ft ft ft ft PE SC Receiv Check#/ Amount Date Permit/ Invoice # Permit ID# Code INFO h Remitted Service Re uest # 42-01 ONSITE WASTEWATER TRTMNT SYST 4/14/18 42-01 ONSITE WASTEWATER TRTMNT SYST 4/14/18