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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 INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS !I S� 9-5 r—, CITY/ZIP Check#/ Cas Amount Remitted 7M A I Permit/ Service Request # CROSS STREET APN ` V PARCEL SIZE , I� p ZyClt SA�,cG�� v OWNER NAME U PHONE y OWNER ADDRESS /' / �( GVe� /�+ CITY/STATE/ZIP ��C� `A I CONTRACTOR 1 t 11 1,0(xv- PHONE (,9 c, 9 ) 65 2,32 22, CONTRACTOR ADDRESS �' CITY/STATE/ZIP M 60IT CCn - r (1. ,(� LICENSE ❑ ❑Cr42 �C-36 OTHER ;fa'ITYI�l / I NUMBER -EXPIRATION DATE -J s� WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION I# TYPE OF WORK: ❑ NEW INSTALLATION REPAIRLADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE ❑ REPLACEMENT ❑ OUT -CF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF Br -.,)ROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEP R& QR4" Y TEM) ^ Ur 41 Jot L e at LEACH LINES ❑ LEACHING CHAMBERS # OF LINES L ur!Es ft DISTANCE TO NEAREST WELL ft FOUNDATION O ft PROPERTY UNE 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. MINI'MHOUR ADV C TICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNEt'� _ _ TITLE !//�//%�sCi DEPARTMENT USE ONLY Application Accepted By Date �rea Employee ID# Final Inspection By Date ❑ SPECIAL PERMIT -Approved by Character of Soimt'O f 3 Ft: PHISump Soil Character: COMMENTS II r .P J� T% �1AIP �l )A] � I A PE Code SC INFO eceived B Check#/ Cas Amount Remitted ate Permit/ Service Request # Invoice # Permit ID# 42-01 it? s�fr�� ✓fir 4/14/18 dv �, ble dc ti � r�o�s be�fl ONSITE WASTEW TER, 1TRTM T SYSTEM PERMIT i ��ZI- 5�,'� v�5� �o.GIjL� oL� VP.ff C.4. ilia l55; -L4,. ° I