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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 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS 312 /b 'E• (209 1�'n oz)EQ /—�' —CITY/ZIP ESC&L-O^I cir3w CROSSSTREET E-AjTt le P ISt AP z Z'f - zvo- Ofj PARCEL SIZE -3 OWNER NAME 1"0141 C A SW CEN l OUT -OF -SERVICE SEPTIC PHONE L*-? 9 T Lf OWNER ADDRESS S m t _-1 COMMERCIAL CITY/STATE/ZIP3(0-01! WIDTH ft LENGTH CONTRACTOR L I t jL' G CO C -NV I Ico1m t /v7i9'� J� PHONE (0 -7 /Q ` D � / ! �Q/i�'( CONTRACTOR ADDRESS 40 -) W • o laoG ST . CITY/STATE/ZIP Lx*t> I e Pt LICENSE _. - C-42 I-].'. C-36 OTHER ` r+ &- NUMBER T I I EXPIRATION DATE L4 - 3 o - 2' WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ LEACH LINES PERC TEST # I BUILDING PERMIT # LENGTH OF LINES ft LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADOITION ENGINEER DESIGNED/ALTERNATIVE WIDTH ft LENGTH REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE _-1 COMMERCIAL 0 OTHER WIDTH ft LENGTH 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 ft FOUNDATION ft PROPERTY LINE 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 # 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 It ❑ 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 ft LENGTH ft DEPTH ft DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH It 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 0 tf0UR ADVANCE NOTICE RE IRED FOR INSPECTIONS PLEASE CALL (2 09) 953-7697 SIGNED TITLE P9-09 ' M &le • DATE 9 "- C ' Z WENT :EIVE® 10 2021 DUIN COUNTY" ONMENTAL DEPARTMENT UC M A 1 IYIG IY I V C VI L Application Accepted y Date //Z4ea ` Employee ID# Final Inspection By 4 ate � l- l (� Ib7i1 SPECIAL PERMIT -Approved by 111 Character of Soil tobepth of 3 FL. Pit/Sump Soil Character: COMMENTS e <t' ,) c . PE Sc Received Check#/ Amount D e Permit/ Invoice # Permit ID# Code INFO Ry Cash Remitted Service Request # 422 Yh4l 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18