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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 (;AZUy .40,1-f 0.4t FOR INSPECTIONS CXPIKtS "I T tAK t-KUM LJA I t ISJUtU JOB ADDRESS 3 �rLL S L CITY/ZIP 6 j/ A/ WELL Q�j (�(X� O � �" I CROSS STREET �/ -2Z APN G� 1 V PARCEL SIZE OWNER NAME zea y4 "I�i% L /Gl _ PHONE OWNER ADDRESS -2-4-2K {��/;rZ, / /, %t ` f C �/ CITY/STATE/ZIP '5-10e//'1 �/ le /II CONTRACTOR VA e S PHONE t5l. y//z � ek �J 3/v CONTRACTOR ADDRESS / V / *0 a / I"I/ CITY/STATE/ZIP LICENSE J;/C-42❑CIC-36 OTHER NUMBER UEXPIRATION DATE WATER TABLE DEPTH: Iy� - I `' ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION #_ TYPE OF WORK: NEW INSTALLATION REPAIRIADDITION ❑ REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIALS ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: W SEPTIC TANK TYPE/MFG / / !/ / d It/ --trJl ❑ GREASE TRAP TYPE/MFG j ft DISTANCE TO NEAREST: WELL ! 3� ft ❑ LIFT STATION SIZE TYPE OF PUMP LEACH LINES Cl LEACHING CHAMBERS DISTANCE TO NEAREST ❑ FILTER BED WIDTH DISTANCE TO NEAREST ❑ MOUNDED WIDTH DISTANCE TO NEAREST SUMPS WIDTH DISTANCE TO NEAREST ❑ DISPOSAL PONDS WIDTH IJ ENGINEER DESIGNED 1 DESTRUCTION C4 OTHER NUMBER OF EMPLOYEES: TERNATIVE S 0(6PACITY �.L .�!/ gal # OF COMPARTMENTS CAPACITY ) gal # OF COMPARTMENTS FOUNDATION / / ft PROPERTY LINE ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) # OF LINES LENGTH OF LINES WELL ft FOUNDATION ft LENGTH ft WELL SC Received INFO B ft FOUNDATION ft LENGTH ya )� ft WELL *3L ft FOUNDATION ft LENGTH ,2 ft WELL 5 D ft FOUNDATION ft LENGTH ft ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH ft ft PROPER � LINE ft DEPTH 71ERft ft PROPERTY LINE S } ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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. ft ft ft ft DEPARTMENT SE Application Accept By '� ? L ' Date y d 1 Area y G G Employee ID#DA Final Inspection By Date ((. 2 oTi ` ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS f' X1 5.11, /hes to : eMei;ii , <O %T setLei 1,k 71z> sv.vll�• -`imb nat be 11e r.kf/MU OFFa Pj_S�InG r jIrl/j'1? +-,Lt,:,4i�n OF ►.Je.I/ ajirJ SDete G,dc•.111JOe ty"r' tPnc.l✓S- PE Code SC Received INFO B ! Che mash Amount Remitted Permit/ Da Service Request # Invoice # Permit ID# ya )� ris VV 1 *3L 2t 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18