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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 HERMIT l �r GALL ZUy Yb3-15YI FOR INSPECTIONS LXPIRES 1 YEAR FROMUATE ISSUEC JOB ADDRESS 1 a ( / ear 2>4 CtirCy� � !r`2 old( CITY/ZIP '7 (-A C1 C-- S �9p� L / �v / CROSS STREET efti e -t 5 APN L 1 � D 16 tj /p PARCEL SIZE y + Ll OWNER NAME /— 1�I PHONE 1 ^7 OWNER ADDRESS/ 7 ' \ GK �y\ y-, -c V / 1 y if S� 1 ` CITY/STATE/ZIP c5 I �1/�. CONTRACTOR ` tC C \/ (�� `�� T G� ✓ v�LQ �J D PHONE 20 J - � 2 % — SCO CONTRACTOR ADDRESS 5413>1 \ ` "^ c CITY/STATE/ZIP Qrl-C^ {J C4 3Q LICENSE [10C -42110C -36,v ❑C-36 OTHER NUMBER f 7 ! EXPIRATION DATE 11 /30j; O� WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVf�L ❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM )( DESTRUCTIONS Sep -AT -4c �11l �l INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG CAPACITY CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT Ion LEACH LINES ❑ LEACHING CHAMBERS LENGTH OF LINES ft ft FOUNDATION DISTANCE TO NEAREST WELL FILTER BED WIDTH ft LENGTH ft PROPERTY LINE ft DISTANCE TO NEAREST WELL DEPTH ft MOUNDED WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL SUMPS WIDTH ft LENGTH ft FOUNDATION DISTANCE TO NEAREST WELL DISPOSAL PONDS WIDTH ft LENGTH ft PROPERTY LINE ft DISTANCE TO NEAREST WELL SEEPAGE PITS NUMBER WIDTH DISTANCE TO NEAREST WELL gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) # OF LINES ReFf7-2 LENGTH OF LINES ft ft FOUNDATION tiaa I O -7.S ft PROPERTY LINE It ft DEPTH ft ft FOUNDATION ft PROPERTY LINE ft ft DEPTH ft ft FOUNDATION ft PROPERTY LINE ft ft DEPTH ft ft FOUNDATION ft PROPERTY LINE ft ft DEPTH ft ft FOUNDATION ft PROPERTY LINE ft ft DEPTH ft 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. SIGNED Wrx IIYJr'r 1, a' `wwJ — rL—CF1JG 4/`YLL L.vJ 17aIJ-1V-71 a TITLE V r�U e DATE 10101MIL� DEPARTMENT USE ONLY Application Accepted Date n//3 JrD Area S f4c Employee ID#_ _ Final Inspection By __ Date ❑ SPECIAL P RMIT -Approved by Character of Soil to Dep I of 3 F . Pit/Sump Soil Character: COMMENTS y/�� n—F \ !O!+'F'l i'i—/n �� ! l�/TPI:.i `-1p��/� �Vi./iV� _ I v •'++ PE SC Code INFO ReFf7-2 heck# as Amount Permit/ Remitted Date Service Request # Invoice # Permit ID# tiaa I O -7.S * Isa 13 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/16 9