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I ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-KEFUNDABLE VERMIT GALL (ZUy)953-/6y/ FOR INSPECTIONS tXPIRES 'I YEARFROMUATE ISSUE[ JOB ADDRESS L CITY� %/ZIP V QA r��L'/ 4- 6 CROSS STREET / APNT ab �% 0� [/� PARCEL SIZE OWNER NAME SCI Snn l . A / A",A PHONE OWNER ADDRESS/CITY/STATE/ZIP �/► CONTRACTOR Y Y I I ¢,,S C � In �•� PHONE L��^ S G ,^^ , S CONTRACTOR ADDRESS ��So CITY/STATE/ZIP /� ` A4'. -� f cl 21 LICENSE ❑ C C-42 ❑ C C-36 OTHER NUMBER XPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: �SIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: I 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 gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) 01 --LEACH LINES ❑ LEACHING CHAMBERS Q # OF LINES LENGTH OF LINES Q(5 I ft DISTANCE TO NEAREST WELL I 001'r ft FOUNDATION ft PROPERTY LINES I 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 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. MINIMUM 48 HOUR 4DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE DATE I S� EPARTMENT SE ONLY Application Accepted By Date Area Employee ID#�P'� Final Inspection By �'�C/k jl�i (4avr.'o &4"l Date IA ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS 46:.r (&CZIGN� PE Code SC INFO Received By Check#/ Amount Cash Remitted Date Permit/ Service Request # Invoice # Permit ID# n( Zf3 Uv 10 Z S12 09'2 13 2 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18