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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 CALL 2J099)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 12-00 2 �S7 K1c /✓► - CITY/ZIP _t._ 9 JOB ADDRESS � ✓ a � /u C 'r J}'1 S CROSS STREET �ll �� CJQ L� APN 07 D�,O )-7 PARCEL SIZE 1 > c OWNER NAME �C�T I -`"1 STZ%� / PHONE OWNER ADDRESS SG1)�Q CITY/STATE/ZIP / CONTRACTOR /VIZ /I c PHONE L90� -;Y CONTRACTOR ADDRESS -/n `�- l"CLN ("�' (moo CITY/STATE/ZIP 5j- !�/Ti/"/I/ (/f !c s LICENSE ❑ ❑ '. -42 '_'C36 OTHER NUMBER �(� EXPIRATION DATE q/30/ a I WATER TABLE DEPTH: L-)O _ c ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: J NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE i REPLACEMENT OUT-0F-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: /` NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: L3G SEPTIC TANK TYPE/MFG " y G/C CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE P ft LIFT STATION SIZE � Z P. TYPE OF PUMP e ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(EN �SI�DY T c g�� ❑ LEACH LINES LEACHING CHAMBERS #of LINES LENGTH OF LINEs 4k 14ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERT ft LJ FILTER BED WIDTH ft LENGTH ft DEPTH ENV/ IN C DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE �Ep TQC ❑ MOUNDED WIDTH ft LENGTH ft DEPTH iV/tzNTft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft SUMPS WIDTH 4/ ft LE NGTH /2 " /Z / ft DEPTH e ft DISTANCE TO NEAREST WELL (-R //•C ft FOUNDATION �s, ft PROPERTY LINE S ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft 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. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 C9�53-7697 SIGNED TITLE DATE ZIr =N 2 D S t DEPARTMENT USE ONLY Application Accepted By Date 7 /3 a') Area 3 % Employee ID#� Final Inspection By Date 7'Za'�� SPECIAL PERMIT-Approved by Cle Character of Soil to D pth of 3 Ft: Pit/Sump Soil Character: COMMENTS s t,54em. Rom Ir IrY1G�p�S;ze� arFx�. A,j90 r�wenJ by pry-t,o-m �rLl v,� ur ClueSlcks PE SC Received Chec Amount DatePermit/ Invoice# Permit ID# Code INFO B Remitted Service Re uest# L-1aLli►s ��3� 3�� I S 0�� e0 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18