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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-KEFUNDABLE PERMIT / GALL ZO9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE JOB ADDRESS// / 3 ',J(n (_f ,2V CITY/ZIP h �, CROSS STREET G�'/,2Z%� APN e-� C --7 7 - /� �' L 7 PARCEL SIZE - C OWNER NAME ( I ayto (' 1 r L S PHONE OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR 010k,I / IA l44 PHONE ,-'2e I/ -?6 �— S _0 "/ CONTRACTOR ADDRESS T �rC f'✓� A" e ID- �jn CITY/STATE/ZIP LICENSE ❑❑�-42 11C-36 OTHER NUMBER S/ EXPIRATION DATE 17 -31— ; S WATER TABLE DEPTH: 7 7 L� ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION 1 ENGINEER DESIGNED /ALTERNATIVE ❑ REPLACEMENT - OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG t; � i � CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS i DISTANCE TO NEAREST: WELL /� '� ft FOUNDATION ft PROPERTY LINE �5 () ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS DISTANCE TO NEAREST ❑ FILTER BED WIDTH DISTANCE TO NEAREST # OF LINES -�) LENGTH OF LINES S_5 ft WELL / C%C! ft FOUNDATION �� r ft PROPERTY LINE S n / ft ft LENGTH ft DEPTH WELL ft FOUNDATION ft PROPERTY LINE ft ft ❑ MOUNDED WIDTH ft LENGTH Check#/ C sh ft DEPTH ft Permit/ Service Request # Invoice # DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH S wo'` ZI:- 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 SEEPAGE PITS NUMBER WIDTH y? / ? FOUNDATION J ft ft PROPERTY LINE ft DEPTH cf S ft DISTANCE TO NEAREST WELL / ,v ft FOUNDATION e)0 r ft PROPERTY LINE g �r 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. DE�Date S ONLY 9 Application Accepted By 21 Area �/ / Employee ID# Final Inspection By 0\ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS S'/ /,? f< PE Code SC Received INFO Check#/ C sh Amount emitted Date Permit/ Service Request # Invoice # Permit ID# 11211 11'7 5 Shy 410 Z S wo'` ZI:- 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 •-7