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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-KEFUNDABLE PERMIT JOB ADDRESS % / - _ I CROSS STREET r GALL ZUY) Yb3-/697 FOR INSPECTIONS E le:k'o UN '0 U �7 p, CITY/ZIP / )s APN Z O / " 172-0-7-2- OWNER Z0^ZZ- OWNER NAME /� �e� i S PHONE S 1 YEAR FROM DATE ISSUED H /-/7 -/7 l�1 PARCEL SIZE > b d OWNER ADDRESS Io ( CITY/STATE/ZIP (� CONTRACTOR N /c' !� eC /P �J�w</ PHONE CONTRACTOR ADDRESS L J��1/ �, �� C� CITY/STATE/ZIP LICENSE DOC -42 ❑❑C-36 OTHER A NUMBER 7f EXPIRATION DATE Z I WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION rhi' REPAIR/ADDITION Ll ENGINEER DESIGNED /ALTERNATIVE FJ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: (SINUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS Permit ID# 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 Check as # OF LINES Date LENGTH OF LINES Invoice # Permit ID# DISTANCE TO NEAREST WELL ft FOUNDATION 30o ft PROPERTY LINE ® FILTER BED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ic7 ft PROPERTY LINE ` ❑ MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH ft LENGTH ft 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 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. IVIIIvIIV/UIVI4 UUK AUVA/VL.0 /VVIR c: KC UIrCCLJ r'UrC IIVar-CL,1miIVa - rLCAJC L'ML-L. LVy VU')-rUVr SIGNED TITLE �i 1'�� DATE ft ft ft ft ft ft ft ft ft ft ft ft DEPARTMENT U E O LYJ Application Accepted By Date �' `s I Area s Employee ID# Final Inspection By kA Z&V% i`j Date kol b Z\ ElSPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft:/� Pit/Sump Soil Character: ace- A - COMMENTS ,�e��Aol , ��c.T w � WCAcr 17e a( . PE Code SC INFO Received By Check as Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# y2/o //5 5 30o 5jZQ0*(3Dq 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4114/18