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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 9$205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED r jih✓l l0� �j7Q,0Vy- �_ CITY/Zip LC'C-4•EPot2D c -A q 62 JOB ADDRESS �31 I ' X s � � - 1 (' PARCEL SIZE �- CROSS STREET T�e'�N APN �� ( - r eD C�cSE�F r 1�►2-�/Gr. SNI DCIS PHONE �� - 11 p, OWNERNAME T�7 / L 3 -1 OWNER ADDRESS ( i � % O N I �E��W � CITY/STATE/ZIP La CkEE=S>� � hJV/ Q.p/�7M �/V'i��'l.r PHONE CONTRACTOR 3�O �i "03?i LIVG OtP'GK GEC• - - A 9! 2`T'� /yXam CITY/STATE/ZIP L� I C CONTRACTOR ADDRESS 1407 W PA- ST• .. LICENSE ❑I:C-42 ❑L?C•36 OTHER L f: V NUMBER ZI I EXPIRATION DATE - �' Z WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y 4 PERC TEST # ( BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION (I REPAIR/ADDITION Ii ENGINEER DESIGNED/ALTERNATIVE 11 REPLACEMENT i.! OUT -OF -SERVICE SEPTIC SYSTEM I.! DESTRUCTION INSTALLATION WILL SERVE: [I RESIDENCE COMMERCIAL ❑ OTHER RESIDENCE NUMBER OF EMPLOYEES: NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: CAPACITY gal # OF COMPARTMENTS Ll SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE CRAP TYPE/MFG ft DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) __..._..___...._..... ... # OF LINES LENGTH OF LINES ft ❑ LEACH LINES LEACHING CHAMBERS ft It FOUNDATION ft PROPERTY LINE DISTANCE TO NEAREST WELL ft L3 FILTER BED WIDTH ft LENGTH ft DEPTH ft PROPERTY LINE ft DISTANCE TO NEAREST WELL It FOUNDATION ft It DEPTH Ll MOUNDED WIDTH ft LENGTH ft PROPERTY LINE ft DISTANCE TO NEAREST WELL ft FOUNDATION ft ft DEPTH LlSUMPS WIDTH ft LENGTH ft PROPERTY LINE ft DISTANCE TO NEAREST WELL ft FOUNDATION ft ft DEPTH L3DISPOSAL PONDS WIDTH ft LENGTH ft PROPERTY LINE ft DISTANCE TO NEAREST WELL ft FOUNDATION ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH f( PROPERTY LINE ft DISTANCE TO NEAREST WELL ft FOUNDATION WITH SAN JOAOUIN COUNTY ORDINANCES, HEREBY CERTIFY THAT I HAVE PREPARED THISAND THE WORK W IACCORDANCE SAN JOAOUIN COUNTY. I LAWSIATON A NDIRULES AND REGULATIONS OF MINIM RA✓uv Ty trvvllL•r-nL DATE - --•-- .%"l / --- TITLE_/ R -V, • t" (r15-' ucrtln I mom.,... .. - - I,•�,. Date /'/ Area I Employee ID# Application Accepted By roved b Date 1.1 SPECIAL PERMIT -App Y Final Inspection By Pit/Sump Soil Character: Character of Soil to Depth of 3 Ft: — COMMENTS 42-01 4/14/18 ONSITE WASTEWATER TRTMNT SYSTEM HERMIT )Vr /�® 721 V7), 17- 42-01 T