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11 ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NUN-KEFUNDABLLE PERMIT (:FILL (ZUyf 9b3-1091 FOR INSPECTIONS//�� EXPIRES 1 YEAR FROM DATE ISSUE JOB ADDRESS i -1 l Cj 1 �1n A Q LLL (4j_ CITY/ZIP /T(. 0 C" CROSS STREET j} toy' ) (; �-e �[�� APN 017 ( 1 0,0 � PARCEL SIZE/ OWNER NAME C.� S 1 'P_Ock�kyo ��o'o etc_ / '/J J7( bV i �`�P W LOO _PHONE (Z0C; 2� 2, 9-S, 611 OWNER ADDRESS S 9 `3 3 L' w s + 11 by, t �� r C I CITY/STATE/ZIP 11 '- C C, W"o �l 1 9 Gy CONTRACTOR Cr" =1 cgT 1-� �- ! PHONE (2_3n) -� + -3 -` D CONTRACTOR ADDRESS 22 � %N1 ' -C> �� `` S� CITY/STATE/ZIP L,-,, (i 1 U I () S 2-(A LICENSE ❑❑C-42 11CC-36 OTHER r \ 3 J NUMBER I I EXPIRATION DATE 9/3 !/Z3 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: D NEW INSTALLATION LI REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATI E REPLACEMENT LI OUT -OF -SERVICE SEPTIC SYSTEM ' DESTRUCTION SPF 1iI L Lei -VIZ INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: 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) ❑ LEACH LINES ❑ LEACHING CHAMBERS Received eck# y Amount Remitted # OF LINES Permit/ Service Request # LENGTH OF LINES ft Permit ANT DISTANCE TO NEAREST WELL ft FOUNDATION o b-9- ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDAI"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. SIGNED Z�Q /lam TITLE DATE DEPARTMENT USE ONLY Application Accepted By �� tt Date 1i 73o,2-IArea ��F� Employee Ioft Final Inspection By �;�, Y( L! r E i� �it�r_ ` E+�. '7. Datel(A`-2 V2 d ❑ SPECIAL PERMIT -Approved Character of Soil to Depth of 3 Ft: h / I Pit/Sump Soil Character: COMMENTS �ruc: w& Ck dj,by r aV 02 `'34W 9n.,. _ PE Code SC INFO Received eck# y Amount Remitted Date Permit/ Service Request # Invoice # Permit ANT 9?,A) ops Ise o b-9- a oGgH3N 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18