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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 CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP CROSS STREET J(/�� APN iJ/7� l Y�/ � �C+ PARCEL SIZE t . a i _ � _... t OWNER PHO OWNER ADDRESS //��L � %%fir �'^ CITY/STATE/ZIP /�, may'{ TJ CONTRACTOR` LrbVll� �' V 'T `l� r�lAlLC�%��C�� //''.. (h� PHONE ��D� �%�/y ' iy r' /�' / CONTRACTOR ADDRESS � �� W'r'u« %L V<<- CITY/STATE/ZIP �/�[' j (� �,�j� LICENSE ❑�-42 ❑❑C-36 OTHER NUMBER J vT�EXPIRATION DA WATER TABLE DEPTH: ❑ PERC TEST # TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPLACEMENT ft GEOGRAPHICAL INFORMATION: BUILDING PERMIT #I Coordinates X LAND USE APPLICATION # REPAIR/ADDITION ❑ OUT -OF -SERVICE SEPTIC SYSTEM INSTALLATION WILL SERVE: � RESIDENCE ❑ COMMERCIAL NUMBER OF LIVING UNITS: f �, NUMBER OF BEDROOMS: ❑ SEPTIC TANK TYPE/MFG �.x►SF) ,N CAPACITY ❑ GREASE TRAP TYPE/MFG CAPACITY DISTANCE TO NEAREST: WELL ft ❑ LIFT STATION SIZE TYPE OF PUMP FOUNDATION ❑ PKG TX PLANT u TERNATIVE ❑ DESTRUCTION ❑ OTHER NUMBER OF EMPLOYEES: gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) lid ❑ LEACH LINES LEACHING CHAMBERS Io C�'9�•,J,,., # OF LINES _� LENGTH OF LINES 7b ' ft i f DISTANCE TO NEAREST WELL ft FOUNDATION %l�ft PROPERTY LINE /O ' ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft O 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 ■ 17 ft FOUNDATION DISPOSAL PONDS WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION SEEPAGE PITS NUMBER � WIDTH .� � ft DISTANCE TO NEAREST WELL /OS � ft FOUNDATION �D � ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE CBO � 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 48 HOUR ADVANCE N ICE RE UIRED FOR INSPE/C�_TIO//NS -PLEASE CALL 209 953-7697 SIGNED TITLE �%/'r're(/'�'� DATE 3' �'�I Application Accepted Final Inspection By Character of Soil to Depth of 3 Ft: TMENT USE ONLY ,d��v///�� "�9) Date Area ��iV_'T_ Employee ID# Date3��f �%� ❑ SPECIAL PERMIT -Approved by Pit/Sumq Soil Character: PE SC Received Check#/ Amount PermiU Code INFO B as Remitted Dae Service Re uest # Invoice # Permit ID# �„�� ? � .- . 42-01 4/14/18 ., ONSITE WASTEWATER TRTMNT SYSTEM PERMIT H d d