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0 ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALnL_ 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE[ JOB ADDRESS -�;),C) h"- ►w CITY/ZIP S C CROSS STREET mG t APN (/ 6:3 -C)6{0 PARCEL SIZE - 2 OWNER NAME PHONE OWNER ADDRESS ^^ /^ CITY/STATE/ZIP r ^� (� CONTRACTOR I I `I, �C�IS Q� �CJ►C.+��f`C� jJ C r • PHONE � `Sy -ry iy (- 9- CONTRACTOR q CONTRACTOR ADDRESS l �/ w x S O CITY/STATE/ZIP.W--t/-t1G� [ 5 3 3 LICENSE 1111C-42 11LC-36 OTHER NUMBER (P6 EXPIRATION DATE _Jd� /7. r c, . WATER TABLE DEPTH: V ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # I HU`��5'�, LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION L ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM r DESTRUCTION INSTALLATION WILL SERVE: ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: -3 NUMBER OF EMPLOYEES: O� SEPTIC TANK TYPE/MFG Ott L. CAPACITY La s» gal # OF COMPARTMENTS Z ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST WELL ft DISTANCE TO NEAREST: WELL jZn I ft FOUNDATION I OI ft PROPERTY LINE l b i ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) G' LEACH LINES LEACHING CHAMBERS # of LINES _3 LENGTH OF LINES I ft hec DISTANCE TO NEAREST WELL 1 ft / FOUNDATION ft PROPERTY LINE Gam_ ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft Code DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft Service Request # 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 fl FOUNDATION ft PROPERTY LINE ft 1 W--'SEEPAGE Ld SEEPAGE PITS NUMBER 3 WIDTH 3( ft DEPTH 2S ft DISTANCE TO NEAREST WELL__t 4i� ft FOUNDATION 10 ft PROPERTY LINE J 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 CO>/1 t -c- f o F DATE .';- X T Character of Soil to Depth of 3 Ft: COMMENTS, Pit/Sump Soil Character: PE SC Received hec Amount ate Permit/ Invoice # Permit ID# Code INFO B ash Remitted Service Request # 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 rA