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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 i (:ALL ZU9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE JOB ADDRESS DISTANCE TO NEAREST / CCITYY/ZIP i CROSS STREET l i t 1 APN 0773(,-00a PARCEL SIZE 1 OWNER NAME) (� DISTANCE TO NEAREST WELL ft �' ! 6r+�I�J �1 < PHONE OWNER ADDRESSp-/! t g/1- CITY/STATE/ZIP CONTRACTOR /� I��. hC`� >� r! 11AW JA' �r -L -k',� - PHONE �% /�n/ j y` �J /J ray—/ �, CONTRACTOR ADDRESS 12.2 "Vel %i / )IA Ali �� CITY/STATE/ZIP 2Ci//��t& ��( `� 7oG /� LICENSE ❑❑C-42 ❑❑C-36 OTHER NUMBER- '0-- EXPIRATION DATE ��.�. 5^ — - WATER TABLE DEPTH: y� _ ` v ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE ❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: -3 NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG CAPACITY CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION _ ❑ LIFTSTATION SIZE TYPE OF PUMP ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS �� # of LINES �_ LENGTH OF LINES 7 �% ft ` DISTANCE TO NEAREST WELL , Q L ft FOUNDATION—ft PROPERTY LINE I r- 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 PROPE41TY LINE ft ❑ SUMPS WIDTH ft LENGTH �� ft DEPTH G/ ft DISTANCE TO NEAREST WELL ft FOUNDATION %(j I ft PROPERTY LINE "L 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. SIGNED wil nY.ar a-ai l lv/rJ - rLCP70C 1 LU.7 VUJ-1 ozrf TITLE GhL �% DATE (/ I IYICIY I VJC WIVLJ I Application Accepted By �i�L�li Date 3 21 Area oZ / Employee ID#_ Final Inspection By Date z 70Z ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: it/Sump Soil Character: COMMENTS �cil s�S�et�, LzisHy►i I1Y1cS io►'P.W►i.��+I r/s�Ih5 lad 90d PE SC Receiv d Check#/ INFO B Cash Amount Remitted ate Permit/Invoice # Permit ID# Service Request # tICode aILl ItsW Zfl 3L -,D t>, 15C( 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18