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t ► A 30?q ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERM rCALL (20&953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE[ Izz JOB ADDRESS 6 1 CITY/ZI/P, L; CROSS STREETJJ4 APN 0 y PARCEL SIZE ' d F OWNER NAME Q PHONE rlL ` } OWNER ADDRESS 3o6s 117 / lY CITY/STATE/ZIP CONTRACTOR PHONE CONTRACTOR ADDRESS, 1 V �� / c1C�ITY/STATE/ZIPY1L LICENSE ❑1702 LSKIC-36 OTHER NUMBER .1XPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: ❑ PERC TEST # BUILDING PERMIT # TYPE OF WORK: ❑ NEW INSTALLATION [7 REPAIR/ADC Coordinates X Y LAND USE APPLICATION # TION ❑ ENGINEER DESIGNED REPLACEMENT ❑ OUT -0F -SERVICE SEPTIC SYSTEM _�( DESTRUCTION ^J Ci III INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: •i TERNATIVE ❑ SEPTIC TANK TYPE/MFG _ CAPACITY _ gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS WELL DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEAC L ES 0 LEACHING CHAMBERS DISTANCE TO NEAREST N # OF LINES ft FOUNDATION FILTE ({BED WIDTH ft LENGTH Amount Remitted Date / n DISTANCE TO NEAREST WELL qda 1 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 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 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 DATE 2021 COUNTY j DEPARTMENTUS ONLY Application Accepted/B�i z1,�� DateDate Area f�•G Employee ID#� Final Inspection By j ] '❑ SPECIAL PERMIT -Approved by Character of Soil to ^epth of 3 Ft: PitlSump Soil Character: COMMENT` /1 z) ;;i aj C. ove.6.,- v7d ne0 Sr -;p r12 c; 1�ts PE Code Sc INFO Received B Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# qda 1 07s Ste-- , Ja 0-71ZI sy DD � O 42-01 l IP / ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18