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E ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-KEFUNDABLE PERMIT GALL ZUy Jb3-/bJ/ FOR INSPECTIONS CXPIRES 'II TEAR FROM UAIE ISSUEI JOB ADDRESS L{ Z ( �C" S / l CROSS STREET AG,5 i, , (i •" CITY/ZI/P, APN 12�� .�/(/.LO �• '75366 PARCEL SIZE ` OWNER NAME i� I lC _� (/% `�-� PHONE OWNER ADDRESS E .S� I L -` ��' `� CITY/STATE/ZIP Ir-, C, ( q 5-3 66 � CONTRACTOR PHONE 7 �6 CONTRACTOR ADDRESS 'J J CITY/STATE/ZIP LICENSE ❑ iC-42 ❑OC -36 OTHER Y3 NUMBER 911 EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION I ENGINEER DESIGNED /ALTERNATIVE ❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM X DESTRUCTION }6( ( A% INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASETRAP ❑ LIFT STATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL SIZE TYPE OF PUMP LEACH LINES LEACHING CHAMBERS ft FOUNDATION DISTANCE TO NEAREST WELL ft FILTER BED WIDTH ft LENGTH FOUNDATION DISTANCE TO NEAREST WELL ft MOUNDED WIDTH ft LENGTH FOUNDATION DISTANCE TO NEAREST WELL SUMPS WIDTH ft LENGTH DISTANCE TO NEAREST WELL DISPOSAL PONDS WIDTH ft LENGTH DISTANCE TO NEAREST WELL CAPACITY CAPACITY ft FOUNDATION ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ SEEPAGE PITS NUMBER WIDTH ft DISTANCE TO NEAREST WELL ft FOUNDATION LENGTH OF LINES _ ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE 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. wnwnn m I'7 I'C HIJVH/Y c ►v i ► c roc iRcu r R nv rc � � w� - SIGNED R, TITLE DATE S 4Lt 11 ( % DEPARTMENT U E ONLY Application Accepted By �r 1 �- Date <% ,) i Area ` �' �., Employee ID# 'A 67 Final Inspection By f `:�Yl.tt�.r C: L Date SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS : � j << i�CtS jy-YP, F•yv!�Ilsh(� f-tiSf lee, rl� 'o� Sr -T !S �/-7 1;;?J �1P>,�e✓, L�<< }1.x;-1-,�'1�,r�� (Inkho:4n. Nt p9WiiS �1� %. }�;r�>J yo G� Tg1t.,lc d (-/-/ L --- ui PE Code # OF LINES ft FOUNDATION Date ft ft FOUNDATION ft ft FOUNDATION ft ft FOUNDATION ft ft FOUNDATION ❑ SEEPAGE PITS NUMBER WIDTH ft DISTANCE TO NEAREST WELL ft FOUNDATION LENGTH OF LINES _ ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE 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. wnwnn m I'7 I'C HIJVH/Y c ►v i ► c roc iRcu r R nv rc � � w� - SIGNED R, TITLE DATE S 4Lt 11 ( % DEPARTMENT U E ONLY Application Accepted By �r 1 �- Date <% ,) i Area ` �' �., Employee ID# 'A 67 Final Inspection By f `:�Yl.tt�.r C: L Date SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS : � j << i�CtS jy-YP, F•yv!�Ilsh(� f-tiSf lee, rl� 'o� Sr -T !S �/-7 1;;?J �1P>,�e✓, L�<< }1.x;-1-,�'1�,r�� (Inkho:4n. Nt p9WiiS �1� %. }�;r�>J yo G� Tg1t.,lc d (-/-/ L --- ui PE Code SC INFO Received B Check#/ Amount Cash Remitted Date Permit/ Service Request # Invoice # Permit ID# iL52,0- 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18