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I ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 PION -REFUNDABLE PERMIT � � JOB ADDRESS a -9/✓ I ��/� CROSS STREET po a OWNER NAME z- CITY/ZIPj /SJ X APN 0 '--0 3 o I PARCEL SIZE PHONE -1-47 T ,dg "r, 15"%3 OWNER ADDRESS ✓ /p v� CITYISTATE/ZIP h ��e► / f �Q 2- CONTRACTOR CONTRACTOR ` PHONE 3 y 2 % CONTRACTOR ADDRESS !� v ` CITY/STATE/ZIP �� n Q2�'/� `/�� LICENSE �42 ❑f'C-36 OTHER NUMBER /��1� EXPIRATION DATE -/ / WATER TABLE DEPTH: ) v _ �+ ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: I I NEW INSTALLATION A REPAIRIADDITION r ENGINEER DESIGNED /ALTERNATIVE A REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: a NUMBER OF EMPLOYEES: P/ SEPTIC TANK TYPE/MFG J /I �/ e I^ CAPACITY �� /� gal # OF COMPARTMENTS -2- ❑ GREASE TRAP L3 TYPE/MFG CAPACITY gal # OF COMPARTMENTS'? ft 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 ReceivedF Amount B Remitted # OF LINES LENGTH OF LINES ft lis' DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 E WELL ft ft PROPERTY LINE ft /REST �F(OUNDATION */SUMPS WIDTH ft LENGTH p 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. / DEPARTMENT USE ONLY Application Accepted By Date 4"D) Area y _/ G e- Employee ID#� Final Inspection By Date ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: it/Sump Soil Character: COMMENTS �� ► ��r� s' "'� h✓t • + e �n� r r }o P.�15�►�nc %t�c�� 11Y1e �% ro-`befrLP(L�15Xc'T is. PE Code Sc INFO ReceivedF Amount B Remitted Date Permit/ Invoice # Permit ID# Service Request # walo lis' 2� 3o0 -Z 2 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18