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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 GALL ZUY yb:f-/bY1 FOR INSPECTIONS `y )�CANIKtb I TCtn ut AK I-KUnAl1JJutl JOB ADDRESS -Q3O / CITY/ZIP ��/DG1VC/✓�� 962Z 5 - CROSS STREET/%�. /'�•r b2 t2 iell APN 1 �^ PARCEL SIZE 7 ! OWNER NAME 4bL//�j �)�(/Gf/ PHONE OWNER ADDRESS-CITY/STATE/ZIP /l CONTRACTOR �Y Fi h�/r� pL &4e, ) )Gn /Y,r_ - PHONE -1-07 CONTRACTOR AAD`DDR'E`SSSr'�ba r 'i�I�ii CITY/STATE/ZIP �� G✓'i �' i 7 / LICENSE /Xk C-42 ❑' 'C-36 OTHER NUMBER ff EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: 0 NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE ❑ REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: : NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG Amount Permit/ f)atq CAPACITY Code gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG Service Req4est # CAPACITY 1►s gal # OF COMPARTMENTS �3DD DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) Its LEACH LINES LEACHING CHAMBERS # OF LINES_ LENGTH OF LINESU ft DISTANCE TO NEAREST WELL IP67 .l ft FOUNDATION 1,2 /� 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 ft FOUNDATION ft PROPERTY LINE ft / SUMPS WIDTH ft LENGTH !f ft DEPTH f� J ft DISTANCE TO NEAREST WELL ft FOUNDATION / /J ft PROPERTY LINE_4- 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 ft FOUNDATION It PROPERTY LINE ft 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. Application Accepted By Final Inspection By__z Character of Soil to Dept COMMENTS ();^d r, TITLE DATE DEPARTMENT USE ONLY Date R-1 Area lN Employee ID# Ff rl CDC(`IAI PERMIT - A—r—.AP&- PE SC Received Ch Amount Permit/ f)atq Invoic O H Code INFO B Cash Remitted Service Req4est # '43,13 1►s 2 �3DD 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18