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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN UOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-KEFUNDABLE VE�RMIT �! (:ALL (LUY) YOd-10YI FOR INSPECTIONS /L-1 LXPIRES "I TEAR FROM DATE ISSUE .JOB ADDRESS % W / CITY/ZIP ze� 1 � QSG) CROSS STREET I ' '�J APN -yD �ll O I PARCEL SIZE OWNER NAME 1f4 cif 1, `1 De _1e_S «f PHONE OWNER ADDRESS ' / CITY/STATE/ZIP CONTRACTOR l�/"`t Q �C PHONE CONTRACTOR ADDRESS 3 7 l�(I/ �4rkYI ' `tk /, p CITY/STATE/ZIP �-! LICENSE ❑ -42 110C-36 OTHER NUMBER Y fOY-< EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT #,2/Oy 55/ 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: NUMB/ER OF BEDROOMS: L_?NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG C� 73 G CAPACITY 100 gal # OF COMPARTMENTS ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG L CAPACITY DISTANCE TO NEAREST: WELL Q ` / ft FOUNDATION SIZE TYPE OF PUMP ❑ PKG TX PLANT gal # OF COMPARTMENTS 30 / ft PROPERTY LINE �76 ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES ❑ LEACHING CHAMBERS # OF LINES 3) LENGTH OF LINES 55 i ft LL DISTANCE TO NEAREST WELL �CC f ft FOUNDATION O / ! 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 3,0 11 ft DEPTH t�`J ft DISTANCE TO NEAREST WELL C9CV ft FOUNDATION 'O ft PROPERTY LINE C"0 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS///- PLEASE CALL 209 953-769 7 ?" � — 6"-a SIGNED TITLE eiyly!/u (/// DATE / EP RTMENT U E ONLY L 0 Application Accepted By V 1. Date FCAArea 1 Employee ID# Final Inspection By Date ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of Ft: Pi Sump Soil Character: COMMENTS �Q_(C 'rQ'�� 1 Z' b 7 �I'� P I C C C X v LENT IVED 2021 COUNTY ENTAL RTMENT PE Code SC Received INFO ABY Check#/ Pash Amount Date Remitted Permit/ Service Request # Invoice # Permit ID# s i 2� X03 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18