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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-KEFUNDABLEPERMIT t:ALL ZUy yb3-/by/ FOR INSPECTIONS tXPIRES "I TEAR FROM UATE ISSUEL JOB ADDRESS o ��^� �(k �r. S C � CITY/ZIP WL c�Id-t 4 16of '7%/� CROSS STREET �yO LA,11 � APN 22 L -W-7 PARCEL SIZE • (!P �� OWNER NAME !� < r-"' I r% PHONE �^ OWNER ADDRESS y� �t� G �1 CITY/STATE/ZIP ^� 6.d= I 'C-"' CONTRACTOR ( i� i� �c.4i<4 a -c- n X Ir - PHONE? CONTRACTOR ADDRESS e6 SC CITY/STATE/ZIP A'4A tif- 1 cot LICENSE ❑11C-42 ❑❑C-36 OTHER NUMBER EXPIRATION DATE Olf-) WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION ❑ PERC TEST # BUILDING PERMIT #�_ TYPE OF WORK: 0 NEW INSTALLATION REPAIR/AD. Coordinates X Y LAND USE APPLICATION # IN n ENGINEER DESIGNED /ALTERNATIVE ri DI i 0"T_0r_CoR1 i = SEPM SYSTEM it DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG CAPACITY CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION _ ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ft ❑ LEACH LINES ❑ LEACHING CHAMBERS # OF LINES ec ash LENGTH OF LINES It Permltl Re uest # DISTANCE TO NEAREST WELL ft FOUNDATION �aIo ft PROPERTY LINE ft 01- FILTER BED WIDTH ' 7. ( ft LENGTH i -D ' ft DEPTH / Ss r� ft DISTANCE TO NEAREST WELL r ft FOUNDATION r ft PROPERTY LINE 5 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 It FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It 1 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. T DEPARTMENT USE ONLY7 1 �r0c-'-v/A� Application Accept e y -T�� Date itkll Area J tolle(GI Employee Final Inspection By Date Z- SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS Ptf O' TJ se( lois 3 a tie piojz 4' w ' t f c�la�'`� tFr� �a the dubie S'rwer >n/ }h)r brei, } ID rFc rC.ilsS Is f' Ise t'Z er r ibase PfI o�rLC'! . ��i� �,il/' 11NAl�C IY 'rl•.�tl1nG � IPiiV1 .a��,9 '/[7 YernUll� (�1��>✓l;�e�(,/%1(/(�![�/1�'11�1frjl- �l'(:?i PE Code SC INFO Received By ec ash Amount Remitted—Service Date Permltl Re uest # Invoice # Permit ID# �aIo ps $� 2 yR© 4C-13 t9 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18