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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 ON-REFUNDABLEPERRMIT CALL Lzmjf 9aimfo FOR INSPECTIONS E��XPIRESS 1 TEFROM DATE ISSUED JOB ADDRESS 9649 t) Wt I�I N�� ✓ CITY/ZIP 71120pc ` 1 57IU T y CROSS STREET M ACS TYtU 2 APN � � � (� ` ' � PARCEL SIZE W • 4q A ' OWNER NAME GLA&5rM3 ?Cm PER+Ai� PHONE Ls�/ 1U�O OWNER ADDRESS I T46 ��1 Li&^I Ciro CITY/STATE/ZIP �h'� � 015m37� CONTRACTOR L.I�E OAX C7'EDME AI��R-{f�%Y� � PHONE 3�`ol7r �/ CONTRACTOR ADDRESS �7 W O A14 � • CITY/STATE/ZIP L 01> � CA � �7' T O LICENSE E# C-42 LII..!C-36 OTHER C�y NUMBER �I�' EXPIRATION DATE T �30 `L7' WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: PERC TEST #___L_] BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION REPAIR/ADD ... REPLACEMENT .... OUT -OF -SERVICE SEPTIC SYSTEM ] DESTRUCTION Coordinates X LAND USE APPLICATION #_ IN IJ ENGINEER DE: Y INSTALLATION WILL SERVE: J RESIDENCE ❑ COMMERCIAL I OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASETRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP CAPACITY CAPACITY ft FOUNDATION _ ❑ PKG TX PLANT .TERNATIV E gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE 1 ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ; LEACHING CHAMBERS JJJ—/ 09/ Amount Remitted # OF LINES LENGTH OF Lwes ft (Z� I Z(� DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft ■■■■■■■�■■■■■■.��i�� 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. SIGNED VA IIYJrCI' I IVIYJ — rLCf1.7C IiNLL ILVJ/ JJJ—/ 09/ Amount Remitted TITLE ��.� • N'tG1e DATE (Z� I Z(� Final Inspection By Character of Soil to SC INFO Received B heck Cash Amount Remitted Date Permit/ Service Re uest # Invoice # Permit ID# ■■■■■■■�■■■■■■.��i�� IIS'.■��'■■■■■■■■■■■■■ ■■■■■■■■■■Gii�■■■■■■�■■■\��Cr■■iC■■■■■■■■■■ ■■■■■■■■■■■■■''ICS■■■■■■►J■��■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■��■i■■►■!i■■■■■■■■■■■■■■■■■■■■!^tib ■■■■■■■■■■■■i�r■■..■■��■■■■■■■■■■■■■■■■■■■■■■�aI W014 ..0; IWOWMA jjj f70Aso Area Employee 1D# COMMENTS 1/ Date 12�1.$f� 2� ❑ SPECIAL PERMIT / PI+!Sump�pil Character: PE Code SC INFO Received B heck Cash Amount Remitted Date Permit/ Service Re uest # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18