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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-REFUNDABLE /PERQMIITT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ' lD I ✓ S SE�/moi o �� 1(�✓ • CITY/ZIP E CALQ N 9 S 3 Z0 CROSS STREET O'qCr-�9R,7L�{G•� SSE �/ /ZD APN 2-c4 Y, -I t D - Zq PARCEL AARCCEL SIZE 3 OWNER NAME C 7x PHONE 700- z-QOG'4 OWNER ADDRESS ITY/STATEMP E-Q NLI)""iCtlr �' •pyi 9.s Z-C7 CONTRACTORLI�E 'rO�K G-ECEi✓I��E��AL PHONE .3t r- 03-7 S ` CONTRACTOR ADDRESS T'01 W 'p1 '- � CITY/STATE/ZIP L19 aI �'4V LICENSE '—: C-42 D C-36 OTHER cc; NUMBER 2"SI EXPIRATION DATE 14--30-2-2- 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: RESIDENCE COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE It ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ....._......................-......_.-.__......._...._._.......................................................................-........................__.._..._ ______..___....----................_......_.._.... _.,_._........._._......._......................_---�d/� ❑ LEACH LINES LEACHING CHAMBERS _ #OF LINES LENGTH OF LINES DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE /V ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft F® DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE -Aoff ❑ MOUNDED WIDTH ft LENGTH It DEPTH f({J/J �o^� DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE�AN ((ftp� C/ ❑ SUMPS WIDTH ft LENGTH It DEPTH fCI T. DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE CPN ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft T TM�N DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINEft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY 0RDINAN ES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMUM 4&HOURA NOTICE REI D FOR INSPECTIONS PLEASE CALL(209)953-769 SIGNED TITLE P/ZVJ' M 6R DATE DEPARTMENT USE ONLY !' Application Accepted —1 G Date f 3 Area '1 U�9 Employee ID# Final Inspection By Date �� 2,� ❑ SPECIAL PERMIT-Approved by Character of Soil to De th of 3 Ft: Pit/Su Soil Ch r: COMMENTS PE SC Received Check#/ Amount Date Permit/ Code PermitlD# Code INFO Remitted Service Re uest# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18