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JOB ADDRESS 3ti2V1 C. pocx- L"-. 1 crrealp ST-DC.J4TIrts...) 1 CROSS STREET STREET CfcaPturr.. R APN 1-11— I4D — 04 PARCEL SIZE Z. r a Arc • OWNER NAME Ebt>1 C. Mc C. oftwl I c.14. PHONE OWNER ADDRESS pC%I4 LP.J • CITY/STATE/ZIP Srpc-k-rb".-1 CA "I 5-2-41)11, CONTRACTOR ig 1E ovet14. 6-a--6 El.., V I 12..D7,1 VP% Eivrekt._ PHONE Ste C)3 CONTRACTOR ADDRESS ADDRESS 41°1 Pti‘ 0 ST-- orris-I-ATE/zip Lot) t '52'-o LICENSE C-42 U C-36 OTHER NUMBER 2- EXPIRATION DATE -30 - INSTALLATION WILL SERVE: b RESIDENCE 0 COMMERCIAL Li OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: WATER TABLE DEPTH: X PERC TEST # ft GEOGRAPHICAL INFORMATION: Coordinates X BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPLACEMENT REPAIR/ADDITION OUT-OF-SERVICE SEPTIC SYSTEM ENGINEER DESIGNED /ALTERNATIVE DESTRUCTION CAPACITY CAPACITY ft FOUNDATION Ci LIFT STATION SIZE TYPE OF PUMP • PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft 0 SAND OIL SEPARATOR (ENCLOSED SYSTEM) 0 SEPTIC TANK TYPE/MFG GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL LEACH LINES LEACHING CHAMBERS # 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 Li 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 ft DEPTH 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. MINIMU 8 OUR nICE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 SIGNED TITLE (2 /2-°-1 • '11' 642- • DATE "2-- I - 2_ I PAYMENT REFEBCE0 11V2E0D21 SANE JOAQUIN COUNTY NVIRONMENTAL HEALTH DEPARTMENT vo,•) 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 DEPARTMENT USE ONLY Application Accepted By Date Date...?// Area Vg Ci Employee ID* As / ( Final Inspection By (n...f C I Date7 U SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE Code SC INFO Receiv y Check#/ ,Cah Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# `1;sidD -5-‘? 2_1 (4- is .2.1-24 51200g32101 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT :SSMICICIV 31IS 4/14/18