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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 JOB ADDRESS CROSS STREET! �C `JDd-fovf FUR INSI'tGIlUNS r-AI'IKtb T TtM Lt AKK I-KUJAIIJJUtI CITY/ZIPG i/ C / APN l r•� 00 / I PARCEL SIZE I S OWNER NAME ��l�P�, PHONE OWNER ADDRESS I ax 0,CCITY/STATE/ZIPLTJ kP (�r� P Po CONTRACTOR 1' Ct yuC PHONE CONTRACTOR ADDRESS 3 L� [✓�� r' CITY/STATE/ZIP LICENSE ❑IIC-42 ❑11C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: ❑ PERC TEST # BUILDING PERMIT # TYPE OF WORK: I I NEW INSTALLATION 4 REPAIR/ADC Coordinates X Y LAND USE APPLICATION # IN ENGINEER DESIGNED /ALTERNATIVE Ll REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM LI DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL z ❑ OTHER NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: V NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG �Y/ S t7` I �� CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS WELL DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) 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. IIIIIYIIII 111 It MLJYM/r%IC Ivw 11%, RL VIIAL✓ I VIl IIVJr LVIIVI• - r /-IJL VI"1LLILL' J •7JJ-IV//JI SIGNED TITLE DATE Final Inspection By j9pK4 Date /0"Vlko- t ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTSFA ling Sy5!e1vl�rob�:b �' rs�7 it liu, rw7, � x/si inti Jlnes ib /Pr,��n)1'e' kcl PE SC Code INFO LEACH LINES I I LEACHING CHAMBERS Permit ID# # OF LINES LENGTH OF LINES '7-O ` ft a DISTANCE TO NEAREST WELL � ft FOUNDATION O O ft PROPERTY LINE -5(51 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 SEEPAGE PITS DISTANCE TO NEARE T NUMBER WELL ft FOUNDATION ft PROPERTY LINE ft ft DEPTH d) ft WIDTH 31 DISTANCE TO NE REST WELL 2 J ft FOUNDATION JC ' ft PROPERTY LINE `fO 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. IIIIIYIIII 111 It MLJYM/r%IC Ivw 11%, RL VIIAL✓ I VIl IIVJr LVIIVI• - r /-IJL VI"1LLILL' J •7JJ-IV//JI SIGNED TITLE DATE Final Inspection By j9pK4 Date /0"Vlko- t ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTSFA ling Sy5!e1vl�rob�:b �' rs�7 it liu, rw7, � x/si inti Jlnes ib /Pr,��n)1'e' kcl PE SC Code INFO Received Check#A Amount B as Remitted Date Permit] Invoice # Service Request # Permit ID# a 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 T