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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 466-3420 IVUN-KEFUNDABLE PERMIT L ALL (ZU`J) &0J-f0&1&0J-f0&1 FOR INSPEGTIUNS tXPIHES I TEAH FHUM UA IF ISSUE O JOB ADDRESS T SA, • -)A" AjT / � CITY/ZIP A --A- '1 PO '7r2-7-0 CROSS STREET DIST �� APN [��7 - D�_D - I PARCEL SIZE I O OWNER NAME S ItC OI LrVc,-.jT Ho I'S t title IAL6EpT1 c/D ClrrallLL.O PHONE `'I0 —109 p e I 11`4 1 OWNER ADDRESS P• O • pOX -+O CITY/STATE/ZIP AC. ftyKPO Ut 1 T.X Z- O CONTRACTOR LI V C O P'tk. GCO EN V 10-oN wj EGFR L. PHONE 3 vy - 03-1 5 - CONTRACTOR ADDRESS �O1 w ' O S'r • CITY/STATE/ZIP LAD t C.h fir ZT Q LICENSE C-42 C-36 OTHER C t'.& NUMBER Z I( EXPIRATION DATE Z Z WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # 4 1 BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE ft DEPTH ft REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM i..l DESTRUCTION INSTALLATION WILL SERVE: - RESIDENCE IJ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL It FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft Permit/ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft sa3 DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION It 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 R AQ14WCE NOTICE RE IRED FOR INSPECTIONS - PLEASE CALL 209) 953-7697 SIGNED TITLE % OACLJ • �y'� • DATE L - 4f' Z I DEPARTMENT U E ONL Y Application Accepted By=,-: Date r7 P Area '1 A1C Employee ID#DA Final Inspection By uc'v , ; I, Q 47.r\c, �, . I\ Date 17 SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: �J COMMENTS C) 14 t7T_.4 S t u9 k,^ -,cd- eo k PE SC Receivedheck#/ Amount Permit/ Code INFO B Date s Remitted Invoice # Service Re uest # Permit ID# aa�a sa3 301 • •21 % 5 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18