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k in 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 LUY Y03-10YI FOR INSPECTIONS GC-X-NIKts I T tAK I-KUM LJAI t ISSUtI JOB ADDRESS A 7 /► t1S CITY//ZIPS ©CFM ,f� CROSS STREET Or, 1-�a (% ^:^ b4 APN l 7 �S �L 79 PARCEL SIZE / y� OWNER NAMEtj '-"�7 / % P -HONE /5 !� OWNER ADDRESSlam, S`� �,J CITY/STATE//ZIIP CONTRACTOR ��'r �il99 4rz' �/'' 1�' /' C' ��yn PHONE CONTRACTOR ADDRESS f^C> I� 7 `�+ e CITY/STATE/ZIP✓ LICENSE ❑ C-42 ❑I IC -36 OTHER NUMBER 4 %t4f/) EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION #_ TYPE OF WORK: NEW INSTALLATION I REPAIR/ADDITION ENGINEER DE: REPLACEMENT I OUT -0F -SERVICE SEPTIC SYSTEM DESTRUCTION Y INSTALLATION WILL SERVE: ❑ RESIDENCE 'X COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: V SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL SIZE TYPE OF PUMP CAPACITY f �zxt CAPACITY ft FOUNDATION ❑ PKG TX PLANT TERNATIVE gal # OF COMPARTMENTS_ gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES D N LEACHING CHAMBERS Invoice # Permit ID# # OF LINES LENGTH OF LINES I _ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE FILTER BED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION 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 ft ft ISTANCETO T WELL FOUNDA11O1 PROPERTY LINE J�SEEPAGEPITS NUMBER WIDTH 1 /^ ft DEPTH / DISTANCE TO NEAREST WELL J T ft FOUNDATION // / �t ft PROPERTY LINE �f I HEREBY CERTIFY THAT 1 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 TITLE DATE / DEPARTMENT USE ONLY I Application Accepted By Date 1 Area 1 Employee ID# Final Inspection ByDate [I SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: PiUSump Soil Character: COMMENTS _ /�/E S55 a- 5R0 0 ft ft ft ft ft ft ft ft ft ft ft ft u PE Sc Received Check#/ Amount Code INFO Cash Remitted to Permit/ Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 T