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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 dn ALL 209 953-7697 FOR INSPECTIONS IEXPIIREES II YEAR FROM DATE ISSUED JOB ADDRESS 1 / ``C�� ITY/ZIP CROSS STREET IT l APN e i V U UC) 1, PARCEL SIZE OWNER NAME V `1 nrr l "L � / I /U PHONE SC7 r % OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR / /GC�� - G "`'' ^ PHONE J7�/ .1 — Y /3 i CONTRACTOR ADDRESS / �� N ix CITY/STATE/ZIP LICENSE 1111C-42 111]C-36 OTHER NUMBER / S`/j:? EXPIRATION DATE � I WATER TABLE DEPTh�J i ft GEOGRAPHICAL INFORMATION: Coordinates X _ Y_ ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION 1% REPAIR/ADDITION ❑ ENGINEER DESIGNED TERNATIVE ElREPLACEMENT 11 OUT -OF -SERVICE SEPTIC SYSTEM 11DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL. ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG L3 GREASETRAP TYPE/MFG ❑ LI FT STATION DISTANCE T'O NEAREST: WELL SIZE TYPE OF PUMP. CAPACITY CAPACITY ft FOUNDATION ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ❑ ft SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES � LEACHING CHAMBERS ��r � � # 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 j9 SEEPAGE PITS NUMBER WIDTH 73 ft DEPTH �A� ft DISTANCE TO NEAREST WELL ft FOUNDATION /�3 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 VI'C I/VJrGIr I IVIVJ 1'LCH JC lr/WLL LVy yA3 TITLE �l nJ /✓�--J��' DATE n4 I mmummENEEMENNEENE MEMEMEMMMENNEMMEM Character of Soil to Depth of 3 Ft: COMMENTS �/,.Cll� T, C Received Check# Amount Dake Permit/ Invoice # Permit ID# Code INFO B as Remitted Service Request # 12.11.20 S v0 X03 .......�.........■......1J1�■■1:■■�■. ■■■■■■■■■ OTY ..............■■.... ■......■■ MIM ■■■■■■ i MEN ..............C..........�,...��..�..........IR4 ONE ■■■ME �■.....■.....�i.■ .■.. -ri...■..�■■■■Q�w1-I Application Accepted By AOL ?Ajj JIF ,►-T/ Mis r`hnr�rfor• PE C Received Check# Amount Dake Permit/ Invoice # Permit ID# Code INFO B as Remitted Service Request # 12.11.20 S v0 X03 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18