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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 t r G"' GALL LUy yDtS C 1 l J-/0Vf FOR 1NSPcJ►UNAF'IKtT tAK I-KUM LJAI t IJJUtI JOB ADDRESS L V ' -G"'.:5 CITY/ZIP �I/l -6c-4 1 L4 CROSS STREET AP N �, ` � 'I PARCEL SIZE OWNER NAME 6 Vv 16IL I'AaI /O i'I' PHONE OWNER ADDRESS I S� -2- hT CITY/STATE/ZIP CONTRACTOR Y r \ \ 1 4e- S 64r C4<('fe C;--'�^I I PHONE 7 .-,�x%�J CONTRACTOR ADDRESS .6 �x &J ID CITY/STATE/ZIP l �f�"14 1 e* LICENSE ❑❑C-42 ❑IJC-36 OTHER NUMBER SS" EXPIRATION DATE �10 .%'2= WATER TABLE DEPTH: DISTANCE TO NEAREST ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # DISTANCE TO NEAREST BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: I NEW INSTALLATION REPAIRIADDITION LI ENGINEER DESIGNED /ALTERNATIVE ❑ SUMPS REPLACEMENT tl _ OUT -OF -SERVICE SEPTIC SYSTEM 6- DESTRUCTION 1 ; INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: OF EMPLOYEES: Q/SIEPTIC TANK TYPE/MFG A ]NUMBER -L- CAPACITY { 7 gal # OF COMPARTMENTS_ ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL IOi I ft FOUNDATION in ft PROPERTY LINE 3rj I ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS WELL ft LENGTH # OF LINES ft FOUNDATION WELL ft FOUNDATION ft LENGTH WELL ft FOUNDATION ft LENGTH WELL ft FOUNDATION ft LENGTH LENGTH OF LINES _ ft PROPERTY LINE It DEPTH ft PROPERTY LINE ft DEPTH ft ft ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 VIA If VJrLV IIVI11J - I-LLAJL {,PILL ILVJ/ JJJ-/ VJ/ TITLE L-Vee� �' DATE I6 ft ft ft ft ft ft ft ft ft ft ft ft T PAR TMEN T,(JSirONLY Application Accepted By - Date Z Zi Area Employee ID#Z— 'Mt /V[%> Final Inspection By ?1?iniI(Ia'i Date 15 ❑ SPECfAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: PiUSump Soil Character: COMMENTS :Vk(-�a - PE SC Code INFO DISTANCE TO NEAREST ❑ FILTER BED WIDTH pu U DISTANCE TO NEAREST ❑ MOUNDED WIDTH DISTANCE TO NEAREST ❑ SUMPS WIDTH DISTANCE TO NEAREST ❑ DISPOSAL PONDS WIDTH WELL ft LENGTH # OF LINES ft FOUNDATION WELL ft FOUNDATION ft LENGTH WELL ft FOUNDATION ft LENGTH WELL ft FOUNDATION ft LENGTH LENGTH OF LINES _ ft PROPERTY LINE It DEPTH ft PROPERTY LINE ft DEPTH ft ft ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 VIA If VJrLV IIVI11J - I-LLAJL {,PILL ILVJ/ JJJ-/ VJ/ TITLE L-Vee� �' DATE I6 ft ft ft ft ft ft ft ft ft ft ft ft T PAR TMEN T,(JSirONLY Application Accepted By - Date Z Zi Area Employee ID#Z— 'Mt /V[%> Final Inspection By ?1?iniI(Ia'i Date 15 ❑ SPECfAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: PiUSump Soil Character: COMMENTS :Vk(-�a - PE SC Code INFO Received Check B Amount Date R mitted Permit/Invoice # Permit ID# Service Request # pu U 6a 12 i S� 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18