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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 /ON/ FOR INSPECTIONS CAPIRES 'I TEAR FROM UATE ISSUEI JOB ADDRESS Z --> z � /�W41 If— 6;;�Z CITY/ZIP. y(�/�%[/ "/ S %G •J� ` )�S CROSS STREET % U �r # OF COMPARTMENTS FOUNDATION % )--I' APN O� I O Opy d Cj PARCEL SIZE 3% ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) DEPTH ft 2,L ��',� OWNER NAME WELL ft FOUNDATION ft PROPERTY LINE ft ❑ PHONE e2c;3 OWNER ADDRESS I ' 0 uX, ft DEPTH ft 1 CITY/STATE/ZIP CONTRACTOR G WELL ft FOUNDATION CX, L- PHONE Oq T—A ADDRESS /b2.2�7 ft LENGTH %L�CONTRACTOR DEPTH ft CITY/STATE/ZIP yPS ,/,/ / DISTANCE TO NEAREST WELL ft ^ ft PROPERTY LINE ft ❑ LICENSE ❑I C-42 ❑' IC -36 OTHER / 1 NUMBER l/ EXPIRATION DATE DISTANCE TO NEAREST WELL ft WATER TABLE DEPTH: AO—I30 ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION . I REPAIR/ADDITION ENGINEER DESIGN ED f ALTERNATIVE REPLACEMENT ul 11 �� 111�PS OUT -OF -SERVICE SEPTIC SYSTEM /7{ DESTRUCTION r(A iQ `< INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL pt r ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 0 PIP -19003's -R-0 NUMBER OF EMPLOYEES: 4 SEPTIC TANK TYPE/MFG t y CAPACITY gal # OF COMPARTMENTS_ ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS FOUNDATION % )--I' 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 LINESOL LENGTH OF LINES ��%%� ft Permit ID# DISTANCE TO NEAREST WELL % -6 ft FOUNDATION % )--I' ft PROPERTY LINE 47-4— 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 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft i SEEPAGE PITS NUMBER WIDTH ) ft DEPTH ? s� 9 ft v DISTANCE TO NEAREST WELL,/4_6 'r ft FOUNDATION 'j i% � ft PROPERTY LINE S ft 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATF I AWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. Application Accepted Final Inspection By Character of Soil to Ila] Area - ❑ SPE Pit/Sump Soil Character: IAL PERMIT -Approved by PE SC Received (qLe9w Amount Permit/ Date Invoice # Permit ID# Code INFO $ Cash Remitted ervice Request # i✓ d 10 s" 2- `13 as 21 Al 5,01 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18