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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTOWCA 95205 - (209) 468-3420 NON-KEFUNDABLE PERM T GALL (" U'J)'Jb3-/6'J/ FOR INSPECTIONS LXPIRES 'I �/� YEAR D AR FROM ATE ISSUE JOB ADDRESS ✓,©O CITY/ZIP � /T Z 2.4IL-1-1f4. , s. / I k3 CROSS STREET .� (,, APN CJO� 1 �� n PARCEL SIZE4. OWNER NAME Y 1/ v L q� LkCOU � PHONE `V n4' OWNER ADDRESS �� I ''l W CITY/STATE/ZIP � � vt� C) �C/I� 1 �2 CONTRACTOR PHONE 3/ CONTRACTOR ADDRESS' 7�/ LD �Q�//V f� C CITY/STATE/ZIP j LICENSE ❑LSC -42 ❑CIC -36 OTHER�NUMBER EXPIRATION DATE Z I WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X ❑ PERC TEST # BUILDING PERMIT # W LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION ❑ R AIR/ADDITION ❑ ENGINEER DI Y L! KEPLACEM T J VDT -VF -SERVICE JEPTIC 1YSTEM I_; DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL [I OTHER NUMBER OF LIVING UNITS: 7\ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ 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 TERNATIVE gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES 0 LEACHING CHAMBERS # OF LINES LENGTH OF LINES ¢r ft DISTANCE TO NEAREST WELL ft FOUNDATION �yl'F ft PROPERTY LINE �' 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 49j<< ft DEPTH �j/S I ft DISTANCE TO NEAREST WELL_ ft 1 FOUNDATION I t��'F ft PROPERTY LINE �S f 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. -MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TITLE I` J DATE /'-'/ 2� D a�k EPARTMENTU ON Y Application Accepted By Date V Area Employee ID#� Final Inspection By "t �°oto Q2 2ft t". d;% Date I I % q 21 ❑ SPECIAL PERMIT -Approved by --rte Character of Soil to Depth of 3 Ft: /t�J� Pit/Sump Soil Character: COMMENTS �T- ✓J� fl D 6.4j '� ;r_-ClSVj(4'y.TgA1 ell= PE Code SC INFO Received y Check#/ Amount ash Remitted Date�7t Permit/ Service Request # Invoice # Permit ID# "2� ' G I 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 T