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s ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-KEFUP JOB ADDRESS CROSS STREET t Qj u-cr OWNER NAME d .9DJ-10.91 FOR INSPECTIONS tXPIRES "I TEAR FROM DATE ISSUE CITY/ZIP Z 1 t� AP V % V l PARCEL SIZE N-5-7 PHONE,,) q 10S .,Z 3 4� OWNER ADDRESS �J 2 L.OI1 C�/� CITY/STATE/ZIP S&C-K-10 CONTRACTOR S-eIILPHONE CONTRACTOR ADDRESS LICENSE ❑ ❑C-42 ❑ ❑C-36 OTHER CITY/STATE/ZIP NUMBER EXPIRATION DATE 17 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION o REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE O REPLACEMENT 0 OUT -0F -SERVICE SEPTIC SYSTEM DESTRUCTION " INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 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 SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDAl'ION 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. MI UM H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE (DLt)Ke�r_ p 2 Zl DATE f ' - DEPARTMENT SE ONLY C Application Accepted B Date q Z Area Employee ID# N Final Inspection By Date l Z Z ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: it/Sump Soil Character: COMMENTSdOWj,w/- e&1,-V,4&f-( f .D�T� fir, • �i6c } /✓✓�J�' '� cz c �rrt/ �*vf- '. r F, ",e elie-e PE Code SC INFO Received B Check Cas Amount Remitted Date I Permit/ Service Request # Invoice # Permit ID# Z2 J 07 5 O 15Z S DU 2 42-01 4/14/18 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT T