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s ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186E E. HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 NON-KEFUNDAISLE V ERMR, I GALL LU}I UOJ-/D'J/ FOR INSPECTIONS tAPIRE3 T T EAR FROM DATE ISSUEL CT? �1 JOB ADDRESS C/. rte,4 FT -7711" C C a T I 7i c- / I CITY121P e '-d". .,U U CROSS STREET ' l/ `r /( APN l `� S ) /- PARCEL SIM 3 OWNER NAME \ ` '9 yU PN'ONE OWNER ADDRESS `/ L Q 1. M y CITYISTATEiLP CONTRACTOR =.MT' 'tI k %/�JwJ /7/_ �f PHONE _, -)C, Cl 3'74' CONTRACTOR ADDRESS x ! /U � ti� /� � CITYISTATE/LP � LICENSE X42 C-36 OTHER NUMBER y�%y t'— ExnRAnoN DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST p BUILDING PERMIT # v AND USE APPLICATION # TYPE OF WORK: NEW INSTALLAnoN EPAIRIADDmoN ENGINEER DESIGNED IALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTI SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER NUMBER OF LINING UNITS: I NUMBER OF BEDROOM$: NUMBER OF EMPLOYEES: SEPTIC TANK TYPEIMFG C CAPACITY 1l n gal # OF COMPARTMENTS ❑ GREASE TRAP TYPEIMFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL 5i ft FOUNDATION ✓L ` ft PROPERTY LINE iC% ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT 0 SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES 4 S ft DISTANCE TO NEAREST WELL R FOUNDATION _ ft PROPERTY LINE / ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It SEEPAGE PITS DISTANCE TO tjA�EST WELL NuneERN�Art W. ft FOUNDATION ft PROPERTY LINET ft � d iA ft DEPTH d I] ft DISTANCE TO EST WELL C;200�IOO "I'" ft FOUNDATION �/D ft PROPERTY LINE C / 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. MIAHMI/M AR bIAIIR AnVdNCF NATICF RFIOI/IRFn FAR INSPFCTIANS - PI FAAF CAl I IWMI WAM7897 SIGNED Application Accepted By f Final Inspection By j Character of Soil to Depth r COMMENTS (�_/ , 42-01 4/14/18 –T. DATE L42 Z/�pMM COON { �FPgR M N �Y DateDate r_ ?I ( �-• Pk/Sump Soil — 7 e Area Employee ID# SPECIAL PERMR -Approved by Date Permitl — Invoke # Permit ION ervice R Uest # ONSITE WASTEWATER TRTMNT SYSTEM PERMIT