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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-KEFUNDABLE PERMIT GA 4L L LU`J YJ3-/O'J/ FOR INSPECT/TUNS CAPIHh, I T hAH t -HUM UA I h I„Uhl JOB ADDRESS 35�-1�yZ_ f 3�*34 W . 5 A 1'-•G-F�T XD - CITY/ZIP ,(-OD I pq s Z � 2- 45-, / s CROSS STREET %-Cy" 1 � APN 0 ��- Iy - O`� 09 PARCEL SIZE 'T5-. 6 OWNERNAME�E A�� / G PHONE OWNER ADDRESS � e `C> D6 -`CW 00 b Y~ - CITY/STATE/ZIP Lea ! 6A I .i �L40 CONTRACTOR 1-1111C O Ar- 6E0eA/WP-00 JM t-1 A L- PHONE 3 d C1 ' U 37 S Q CONTRACTOR ADDRESS '4O, �' d�+�K fr' CITY/STATE/ZIP L"-01 C� LICENSE E' C-42 00;C-36 OTHER ` NUMBER Z (� ( EXPIRATION DATE Y- - 3D L•L WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y X PERC TEST # 1 I 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 LI COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL It FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft 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 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 It 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. MINIMUM 491HOUR ADI ANCF NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TITLE %k-c'J l" G -A • DATE `I ` 2 Z I , RM x -----------------------------------------=•- ----------- - -- ---T- - — - -- _ � _SARGENT RtR sccno.9 uxc _ _ _ — _ _--- waa9• �. ..t1`-. Sea• $• ;k' �l i- �� � �� ce o-- 3 'L. J ---- I I i • \>�:�I �]1� -LX ia:r p, -T 1-, L 2021 I SAN JOA • L J J ENVIRONM COUNTY ENL gill EALTH DEPARTMENT tax, a, 9 5 9.99 N 919-.19-0.9, SYN. N, - iI- UC I I - SAq�NI Faia Paws. uc a. 20rB-i053� AR DEPTMENT S O LY Application Accepted B Date Area! 9 Employee ID# Final Inspection By Date ❑ SPP CIAE L PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sum� Soil Character: COMMENTS`l_ PE SC R ' ed Check#/ Amount Permit/ Invoice # Permit ID# Code INFO Remitted Pat Service Request # 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18