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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-KEFUNDABLLEE jPERM`IT CALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR F OM DATE ISSUE] JOB ADDRESS�) CITY/ZIP _5 x ��,✓`� 2 //` l CROSS STREET ,/)J�'Cqf/�j�J.�d� /'. APN �� 5 /y r' l ( PARCEL SIZE OWNER NAME /yl�C1/�/� �/� F��', 4 (/ PHONE OWNER ADDRESS LeA r YIe CITY/STATE/ZIP -7 ? CONTRACTOR c1�Q ,t/ .' �� Q -S�G� PHONE -S— CONTRACTOR CONTRACTOR ADDRESS f / � / 1 W,�J� CITY/STATE/ZIP LICENSE ❑❑C-42 ❑❑C-36 OTHER NUMBER EXPIRATION DATE/ Ly ? 7 WATER TABLE DEPTH: "7 6 - tFU ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION tp REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE ❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: FAF RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG CAPACITY CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) \ LEACH LINES !$' LEACHING CHAMBERS Q 3 # OF LINES / LENGTH OF LINES 7 a ft , Amount Remitted V_( Permit/ Service Request # DISTANCE TO NEAREST WELL ft FOUNDATION _ ft PROPERTY LINE / _� ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft L DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft Area DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ® SUMPS WIDTH ft LENGTH e-- S ft DEPTH / --e— ft Character of Soil to Depth f 3 Ft: DISTANCE TO NEAREST WELL ZJ ft FOUNDATION e"0 r ft PROPERTY LINE / r ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft O»P �tliP �J b��bcrnG�y%1QP/�. No lni*r � 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. SIGNED TITLE ::f 4;W �/%✓� DATE Amount Remitted V_( Permit/ Service Request # Q IN cOUNTY AEll1 Permit ID# N�►� I O M ENT T L DEPARTMENT US ONLY L4/67 61 FrO. G Application Accepted By Date d Area Employee ID# Final Inspection By G Date (� t ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth f 3 Ft: Pit/Sump Soil Character: COMMENTS Peloew H% l eoc J 1Le for npW ffon�porch. O»P �tliP �J b��bcrnG�y%1QP/�. No lni*r � l��e 5ya11 be. of be'1(r,uen t,tier. PE Code SC INFO Received y Check#/ Ca h Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# N�►� �►� S �3OD 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18