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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 PERMIT CALL ZU9 953-769/ FOR INSPECTIONS tXPIRES "I TEAK HKUM UAI t ISSUtI ✓ JOB ADDRESS cG%I / CITY/ZIP C YI (� CROSS STREET ` 1 r, l! I APN Ob 3I d O I PARCEL SIZE �/ O OWNER NAME I,// !To'j S PHONE OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR CG{/4'41 b Gf C / el PHONE "?c ( — JCC? [ 7 /O Q z 1.� ire' / r' CONTRACTOR ADDRESS `� - 1 � �Ul�e4o I� �j/Dr- CITY/STATE/ZIP .54'64/041y� r�64- LICENSE ❑.C-42 ❑❑C-36 OTHER NUMBER �5/'� T EXPIRATION 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 I OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ,�"" RESIDENCE ❑ COMMERCIAL 2 [I OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: (J) NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG �i�s "'� �l'�r��"� CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG - -Permit ID# CAPACITY gal # OF COMPARTMENTS )is DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS # OF LINES_ LENGTH OF LINES �� ft DISTANCE TO NEAREST WELL /00 ! ft i FOUNDATION 30 ' ft PROPERTY LINE 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�NAREST WELL ft FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER WIDTH 3& DEPTHpIF �' ft ft �j ! DISTANCE TO NEAREST WELL l 5 d ' ft FOUNDATION $PO ft PROPERTY LINE 30 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. DATE /—a5—a-1d' DEPARTMENT USE ONLY 1 G% Application Accepted By GZ— Date I a7 5 Area Lr 1 Employee ID# i it Final Inspection By 1 Date % ,�-% ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS �sXs*Y►�! �x►slh� lih�s rPl►'GIJr1 PE- Code SC INFO Receive Check#/ Cash Amount Remitted Date Permit/ Service Reguest # Invoice # - -Permit ID# L)a►D )is 30c) 25 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18