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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 209 953-7697 FOR INSPECTIONSc EXPIRES 1 YEAR FROM DATE ISSUE JOB ADDRESS �`��©/ ! �%� �! �� CITY/ZIP 2� Z 7 CROSS STREET O ^ � ( �G`Z/ APN �� - OG- 1-217 PARRCEL /SIZE J 7 /��JC/ �7 / OWNER NAME PHONEd" OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑ C-42 ❑ C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE 9 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. mnv►►w in Yo v v r r !Cc vrr�c� rvr� nv rc ► r IY - rLCH C NLL cvy -i i SIGNED TITLE �: DATE S' +^ T Application Accepted By Area Employee ID# I Final Inspection By Date ❑ SPE IAL PERMIT -Approved by Character of Soil to Depth o Ft: Pit/Sump Soil Character: COMMENTS fj LSl T�tltsi A&Z,C�JtggY PE Code SEPTIC TANK TYPE/MFG S C� /AY L CAPACITY / J U U gal # OF COMPARTMENTS — ❑ GREASE TRAP TYPE/MFG �19,)ooiD CAPACITY 2 gal # OF COMPARTMENTS �/� DISTANCE TO NEAREST: WELL AZI VL �i LFOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS �Z_ cx- l��// # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL Jyl/I/ i 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 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. mnv►►w in Yo v v r r !Cc vrr�c� rvr� nv rc ► r IY - rLCH C NLL cvy -i i SIGNED TITLE �: DATE S' +^ T Application Accepted By Area Employee ID# I Final Inspection By Date ❑ SPE IAL PERMIT -Approved by Character of Soil to Depth o Ft: Pit/Sump Soil Character: COMMENTS fj LSl T�tltsi A&Z,C�JtggY PE Code SC INFO Received Ch k#/ B C Amount Remitted Date Permit/ Service Re uest # Invoice # Permit ID# �19,)ooiD 4ZUD. 2 42-01 4/14/18 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT