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t I ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-KEFUNDABLE VERMIT CALL ,ZUJ `40.S -t0.41 FUR INSPEC11UNS CxF'IKLb I TLAK t-KUM 1JAIt ISSUtl JOB ADDRESS 21 e CITY/ZIP ESeG or 9sadb CROSS STREET LiveAPN 2-4-1 C) _ 2 PARCEL SIZE 2A/ (' OWNER NAME N ckaV' 4Ll W(�I� -� �lQ v ' • "•'v� PHONEI h1C) q / 6' O 1 WY 1 OWNER ADDRESS e' S �N,/' *� ul. CITY/STATE/ZIP a I V ►r (iA CONTRACTOR PHONE CONTRACTOR ADDRESS LICENSE 0!!C-42 ❑LIC -36 OTHER CITY/STATE/ZIP NUMBER EXPIRATION DA WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y C' PERC TEST # BUILDING PERMIT # - CO l'b'V7 LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION INSTALLATION WILL SERVE: 19 RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: ' NUMBER OF EMPLOYEES: A3 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) Application Accepted By �✓�"� Final Inspection By Character of Soil to Depth of 3 Ft: DEPARTMENT SE ONLY Date 113 dvab Area "1 / Employee ID# Date?, 25 .Z ❑ SPECIAL PERMIT -Approved by Pit/ ump Soil Character: PE SC Code INFO LEACH LINES - LEACHING CHAMBERS alo 1I,-- # OF LINESI _ LENGTH OF LINES 3 2 LE ft DISTANCE TO NEAREST WELL 111 t ft FOUNDATION 4o ft PROPERTY LINE 10 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, S-YATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. Application Accepted By �✓�"� Final Inspection By Character of Soil to Depth of 3 Ft: DEPARTMENT SE ONLY Date 113 dvab Area "1 / Employee ID# Date?, 25 .Z ❑ SPECIAL PERMIT -Approved by Pit/ ump Soil Character: PE SC Code INFO Received tPjckV By ash Amount Date Permit/ Invoice # Permit ID# Remitted Service Re uest # alo 1I,-- (0,-,3 2- �3,:)0 1 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18