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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 LUY y03-10YI FOR INSPECTIONS t_XPIRES 9 YEAR FROM UATE ISSUEI JOB ADDRESS 419—-� /(-/ /°'/-<-/C_ A?v CITY/ZIP_ TT / L CROSS STREET Z2,z{ z j f i� /APN O � � u I ✓ PARCEL SIZE OWNER NAME �r ��'�J < /io_S PHONE OWNER ADDRESS? -Z -C— CITY/STATE/ZIP CONTRACTOR �i�� 1��G PHONE? CONTRACTOR ADDRESS �GCirr�� /�/C CITY/STATE/ZIP/ LICENSE ❑A-42 ❑❑C-36 OTHER NUMBER /5 �1U �� EXPIRATION DATE,:;�`J/�3 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. IVIIIY/ IVI -FO r7VVn HU VHIY C 1VV I 1%.,C rNC UIPCCU r - R 11Y rC I / IIV - rLCN C HLL 1ev, SIGNED --4�-- TITLE DATE T _ DEPARTMENT USE ONLY Application Accepted B �/� �L ate Area (%� Employee ID# �� a \• Final Inspection By ° CLI Date VIYU ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS12er ,�<l`J �•. -1 2 - PE Code , Received Py JCa Check#/ WATER TABLE DEPTH: ) V ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # d I D;3 / 5 LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE ()a--) REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ta. RESIDENCE F1 COMMERCIAL ❑ OTHER NU MBERR OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK / TYPE/MFG G CAPACITYU�U gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL �0 / ft FOUNDATION w ft PROPERTY LINE / ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) I� LEACH LINES LEACHING CHAMBERS # OF LINES -3 LENGTH OF LINESS//S ft DISTANCE TO NEAREST WELL �S L r ft FOUNDATION >� ft PROPERTY LINE Yy 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 SEEPAGE PITS NUMBER WIDTH y ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION 757 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. IVIIIY/ IVI -FO r7VVn HU VHIY C 1VV I 1%.,C rNC UIPCCU r - R 11Y rC I / IIV - rLCN C HLL 1ev, SIGNED --4�-- TITLE DATE T _ DEPARTMENT USE ONLY Application Accepted B �/� �L ate Area (%� Employee ID# �� a \• Final Inspection By ° CLI Date VIYU ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS12er ,�<l`J �•. -1 2 - PE Code SC INFO Received Py JCa Check#/ Amount Remitted Date I Permit/ Service Request # Invoice # Permit ID# ()a--) 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18