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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 r n CALL 209953-7697 FOR INSPECTIONS p� EXPIRpES 7 TEAR FROM DATE ISSUED JOB ADDRESS 4214 �L}�-y�L�I 7Ez� f`%> /- CITY/ZIP Get a I I S193 Z / CROSS STREET A/ •}- �7' G F'DK� E �.�q.y��,v1 6 APN DOJ � 3'1 0 � 31 PARCEL SIZE r•, Z Ac . OWNER NAME J Erp ; /-�7/AIV(Ny C tf►�1�m A N PHONE 3 2 y ft 3341 OWNER ADDRESS /41 / r,.. A L.. L� /� � CITY/STATE/ZIP7 GG[ ` LT r C.�/� i S iia Z CONTRACTOR LI V E 0 A le. Geo 67b# � (20 /�� v 1 F � � PHONE 3L / '- 037 S G'� �J CONTRACTOR ADDRESS 44 0 � po ' 0 A� ST • 1 CITY/STATE/LIP L -OD ( CA / � Z 47 6 LICENSE L iC-42 ❑I :C-36 OTHER C c v NUMBER 02't 5 ( EXPIRATION DATE 4 ��y � TZ WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: PERC TEST # I BUILDING PERMIT # TYPE OF WORK: ._. NEW INSTALLATION ._. REPAIR/ADE Coordinates X Y LAND USE APPLICATION # .... REPLACEMENT .... OUT -OF -SERVICE SEPTIC SYSTEM I; DESTRUCTION INSTALLATION WILL SERVE: _ RESIDENCE U COMMERCIAL U OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASETRAP ❑ LIFT STATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL SIZE TYPE OF PUMP _ CAPACITY CAPACITY ft FOUNDATION . ❑ PKG TX PLANT TERNATIVE gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE 1 ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS Chec Cash # OF LINES LENGTH OF Lwes ft Invoice # Permit ID# 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 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 HOUR ADV CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE jo2Cua VNl&IZ DATE I Z -I" 2 (0 •� UCYAffI MINI USt UNLY L� /� Application Accepted B Gj� �-'�--- Date 3 a1 �J�� Area I � Employee ID# DfF, Final Inspection By Date � ?. � ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: f I P t/Sump Soil Character: COMMENTS &wr_ V�^Aj /0 _/7 ! ✓1 i/2f� PE Code SC INFO Received Chec Cash Amount Remitted Date PermiU Service Re uest # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18