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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 ZUY Y03 -/6y/ FOR INSPECTIONS tXPIRES I Y^ UATE ISSUEI JOB ADDRESS /:(4.��'I �I T��/EGL aA CITY/ZIP /YIAAjM,-A 96-376 . ( 4 6-376 CROSS CROSS STREET "07'f1l.. ,414 APN a f g —0619-4910 PARCEL SIZE p • 7k OWNER NAME Shy IAIVEST� r�/T 449meAd LLL ` PHONE �Q�_ J o f —1 /23 OWNER ADDRESS 1433 Ao)cO F,4 r BL ✓O. CITY/STATE/ZIP MA/V77E4 4 . CA 75-31C CONTRACTOR PHONE CONTRACTOR ADDRESS � CITY/STATE/ZIP QS� Bn 7. LICENSE 110C-42 DDIC-36 OTHER NUMBERC/77 % EXPIRATION DATE W ER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: G NEW INSTALLATION Fl REPAIR/ADDITION fl ENGINEER DESIGNED /ALTERNATIVE E. REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM F'. DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP CAPACITY gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS ft FOUNDATION ft PROPERTY LINE ft _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS Received B # OF LINES Amount Remitted LENGTH OF LINES Permit/ Servipe Request # DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ FILTER BED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDA11ON ft PROPERTY LINE ❑ MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 L DATE /a -4--V PARTMENT SE NLY ��—L Application Accepted By G -- Date 112Area Employee ID# Final Inspection By 11_Date�Z l S��U ❑ SPECT L PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS ft ft ft ft ft III ft ft ft ft ft ft PE Code SC INFO Received B Check#/ Cash Amount Remitted Date Permit/ Servipe Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 T