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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-KEFUNDABLE PERMIT (-ALL( (ZWO /5.f -/O // FOR INSPECTIONS tX,PIIR�ES "I YEAR FROM UATE ISSUEI JOB ADDRESS (Q��(�� 0 -r5 [0- i 1-Y 1 G\1/ CIITCi TYIZIP _ �`�oG� 7'on l C CROSS STREET { ��_1 �-?- to L� APN O �%V S O ` C)_7 PARCEL SIZE JI� OWNER NAME L;L 02 m e ciP10 Fro nx PHONE OWNER ADDRESS SG w CITY/STATE/ZIP U'^y^, 1 CONTRACTOR } I K, PHONE 44 �, -1-1961 5 - CONTRACTOR ADDRESS pO 16ax (j/' t'� CIN/STATE/ZIP y✓ l aa G�9-( CdA- � � _ LICENSE i. C-42 ❑'_:C-36 OTHER NUMBER -EXPIRATION DATE V Z_ WATER TABLE DEPTH: 70 D `' ft GEOGRAPHICAL INFORMATION: Coordinates X Y r] PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE L, REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: & RESIDENCE I COMMERCIAL LI OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: __3 NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG �� _ CAPACITY n /{ gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS WIDTH DISTANCE TO NEAREST: WELL ( j_'�nt ft FOUNDATION 131 ft PROPERTY LINE -?0 ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ,� - Ul LEACH LINES LEACHING CHAMBERS 1 # OF LINES LENGTH OF LINES 6 ft qd 1 D 153 DISTANCE TO NEAREST WELL Fj I ft FOUNDATION b I ft PROPERTY LINE 101 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 TD NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TD NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft O�EPAGE PITS NUMBER l WIDTH L4� I f ft DEPTH 2J 1 ft DISTANCE TO NEAREST WELL I ft FOUNDATION �� I ft PROPERTY LINE 1 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. SIGNED L � TITLE /'rp�%tocryCGl� DATE 2 (� �! Application Accepts Final Inspection By Character of Soil to COMMENTS h Area Employee ID# J/F t SPECIAL PERMIT -Approved by r' k r + PE SC Received Code INFO By eck# Amount ate Permit/ Invoice # Remitted Service Request # Permit ID# qd 1 D 153 S 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18