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w 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 209 953-7697 FOR INSPECTIONS L ,/ EExPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �3 Cl-n I{ CITY/ZIz U�-L-/0 C� I I _ !I G,GILS f/�/y� m CROSS STREETp U le(le- �-/ ` APN I�' 1�'�1 O -CM) PARCEL SIZE'r-000, /�lJ�lli fit, p OWNER NAME �l�rml� �J GrLSS �O IC'`I PHONE�O/ '-Y01-17�� a m C1 f � Sit, `�� 1 C} v, OWNER ADDRESS L-3 o-51 J I�// /�l�i/C l'.� CITY/STATE/ZIP�,,c_y-&n /-7 / 5`� Q 2 CONTRACTOR O,Iy)c1 PHONEc-�e-1- VQ CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑LIC-42 ❑I IC-36 OTHER NUMBER 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 ENGINEER DESIGNED/ALTERNATIVE ,y REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION I Ui�I I� INSTALLATION WILL SERVE: C RESIDENCE ❑ COMMERCIAL C 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 ft 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 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 It 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 It 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. (yMUM 48 HOUR ADVANCE NWICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 9953-76--9��7�,�.--��/`7 SIGNED C/Z TITLE r DATE / p(lt�YJ NT �0 ,y 20 N Nry T DEPARTMENTUSE ONLY Application Accepted B Date 9 0 q Area a G Employee ID# . Dom_ Final Inspection By Date ❑ SPECIAL PERMIT-Approved by Character of Soil to Deo of 3 Ft: Pit/Sump Soil Character: COMMENTS Demo re5)6-let a-. )ikyi sewer div S mi K-0cL ,_�-3�IyP.✓P "-.-Y G�f PE SC Received heck#/ Amount Date Permit/ Invoice# Permit ID# Code INFO B y as Remitted Seryice Re uest# Naa 1 o7S l`f�e� � iSd 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18