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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^- CALL 09 953-U97 FOR INSPECTIONS EXPIRES 1 YEAR FRO ATE ISSUED JOB ADDRESS / GY/jl/x O6a*`fi CITY/ZIP CROSS STREETfz= ljlj APN DOy PARCEL SIZE / OWNER NAME ��r� (C� �Z— PHONE OWNER ADDRESS �:SC? �CITY/STATE/ZIP CONTRACTOR ( 2A: / A / e PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE 1L',C-42 11L_iC-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: I i NEW INSTALLATION I REPAIR/ADDITION i ENGINEER DI Y NED /IALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM % DESTRUCTION tG/ )"I I<, INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP ❑ LEACH LINES I I LEACHING CHAMBERS CAPACITY CAPACITY ft FOUNDATION ❑ PKG TX PLANT # OF LINES gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ft ft ft ft ft LENGTH OF LINES _ ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE ft ft ft ft ft ft ft ft ft ft ft 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. MINI 48 VAN E- E REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-769 SIGNED TITLE ��Y� DATE //Z 2 / DEPARTMENT US ONLY /� Application Accepted B �� Date �? ? Area sick {il>7 Employee ID# %/ /-5 Final Inspection By_ Date zoZi ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS Cy1I7C-- i)n< 41b c i fy .-,eV4'e - PE Code DISTANCE TO NEAREST WELL Check#/ Cash ft FOUNDATION FILTER BED WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION _ MOUNDED WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION _ SUMPS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION DISPOSAL PONDS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION _ SEEPAGE PITS NUMBER WIDTH DISTANCE TO NEAREST WELL ft FOUNDATION gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ft ft ft ft ft LENGTH OF LINES _ ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE ft ft ft ft ft ft ft ft ft ft ft 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. MINI 48 VAN E- E REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-769 SIGNED TITLE ��Y� DATE //Z 2 / DEPARTMENT US ONLY /� Application Accepted B �� Date �? ? Area sick {il>7 Employee ID# %/ /-5 Final Inspection By_ Date zoZi ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS Cy1I7C-- i)n< 41b c i fy .-,eV4'e - PE Code SC INFO Received Check#/ Cash Amount Date Permit/ Invoice # Permit ID# Remitted Service Request # as 1 0-7 S- VL$-*- I� 1-) 1. q 42-01 // �/ � / 2 2j 7 6 � ` ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 l//�•' -_`�•�`1 c