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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-REFUNDABLE(PERMIT � ) 1/ �f �r CALL1 (209)953-7697 FOR INSPECTIONS / EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS v2� /D !.'�/ • 1Oc� C�m� T� AVe CITY/ZIP�Md--i ldt'c2 5&_�7-7 CROSS STREET e / e APN PARCEL SIZE D j / A OWNER NAME PHONE OWNER ADDRESS �W�� /^J� C L �►!� �� CITYISTATE/ZIP h' z4ao k C.� CONTRACTOR �Le-,7Z eZ n ll C�] �/� / 1/►C. PHONE^,� 1; - 91y'97.2S CONTRACTOR ADDRESS ms%•'3 �(,y (GL�p Cj� /�P/ CITY/STATE/ZIP _��jrt'GL�i`'yyy eX SIS 3cq LICENSE ❑LC-42 ❑ 1C-36 OTHER S NUMBER 5��^$� EXPIRATION DATE �r— (, WATER TABLE DEPTH: I� ?� ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION!# TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGN D/ALTERNATIVE ,�-O REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: sNUMBER ,OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG /�� C �i^ I^iK CAPACITY fa GO gal #OF COMPARTMENTS d.0 ❑ 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 I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft FILTER BED WIDTH ,,Z�J/ ft LENGTH / ` ft DEPTH S ft DISTANCE TO NEAREST WELL &I C) ft FOUNDATION Aw /O ft PROPERTY LINE _.5 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 ft DEPTH ft DISTANCE TO NEAREST WELL ft 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. MINIM 8 UOUR ADVANJ2E NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL 209 95/3-7697 SIGNED TITLE �� 4- DATE 10 J C B T TW�4+ #1 1 N DEPARTMENT EONLY Application Accepted y Date Area Employee ID# kV"4b* Final Inspection By Date Z Z51W ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 t: Pit/Sump Soil Character: VC COMMENTS � 2 0 a o s ho e -�' rz, e- -an. PE SC Received eck#/ Amount Date Permit/ Invoice# Permit ID# Code INFO By S Remitted , Service Request# AR d O Id42-01 �j1'O (`I GG n (3x/ `��O ✓` -A0,VNS,-T`E ASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 / _