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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 �yG�ALL 209 953-7697 FOR INSPECTIONS EXP PII rRES 1 YEAR FROM DATE ISSUED JOB ADDRESS I le 01 d A . �>t 1 � W" xt> r- CITY/ZIP L"p� ( / S 2'4+C) CROSS STREET K11E..��.EAPN C%J I " ZCM " V" O* � �(V -7PARCEL SIZE Ile OWNER NAME 1A„R•1 0 001>9 IG E L PHONE IDI ft 153 O<o(+(o OWNER ADDRESS �- • PiAi c ST • ,6 CITY/STATE/ZIP L ou%> I , GA q S 2� %4o CONTRACTOR LIME OItiL CTei-J�i,EtyV I o rjyAE� A L- PHONE 3 (0 / ` 071500 L' CONTRACTOR ADDRESS 41O'7 w • V' `W ST' CITY/STATE/ZIP `OD I � C'S LT V LICENSE ❑ ..'C-42 UI:: C-36 OTHER Ce NUMBER 7A V ( EXPIRATION DATE y,3 0" ZZ WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: PERC TEST # BUILDING PERMIT # TYPE OF WORK: ._. NEW INSTALLATION .... REPAIR/ADC .... REPLACEMENT ._ OUT -OF -SERVICE SEPTIC SYSTEM I.'. DESTRUCTION Coordinates X Y LAND USE APPLICATION # INSTALLATION WILL SERVE: L� RESIDENCE U COMMERCIAL G OTHER # OF LINES NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ft 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 gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE I ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES i LEACHING CHAMBERS Check s # OF LINES LENGTH OF Lwes PermiU Service Re uest# ft 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 8 HOUR A VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE �QOJ ' M i� & DATE 1 Z " 1 1 ` 2 O y m d O DEPARTMENT USE ONLY Application Accepted B ��< Date r�J '7ta _ Area I "� �V Employee ID# V� Final Inspection By Date v�l� ❑ SPECIAL PERMIT -Approved by Character of Soil to th of 3 Ft: Pit/Supp Soil har t COMMENTS -P� r_ ✓ 0 U � /9qO� 0 . i 41 / 1 UI L t/ lAti PE Code SC INFO Received B Check s Amount Remitted Date PermiU Service Re uest# Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18