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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 3 JOB ADDRESS IP_S�}0 S GALL vlo%'4 JS.i-1091 FOR INSPECTIONS CXPIKtS "I T LAR I-KUIVI UAI t IJJUtl % �%� J y� CITY/ZIP .�'��l�-�r� �d+ CROSS STREET C./D��'✓ /�' ell APN l /OS 9 00 Q S PARCEL SIZE OWNER NAME " I �� [/C y�X PHONE OWNER ADDRESS I/ ! - CITY/STATE/ZIP �y �j CONTRACTOR n a / nl`V/�'/ l /2/yam/'/�" c/� {� PHONE ok J� 5 CONTRACTOR ADDRESS / 'CCY �r(r�-K�EH / -/ J� /�I /IQ CITY/STATE/ZIP LICENSE ❑I -42 ❑0C-36 OTHER NUMBER J 7d 5 EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # c2l()q7� � LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT i.] OUT -OF -SERVICE SEPTIC SYSTEM n DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: � /❑ ❑ SEPTIC TANK GREASE TRAP LIFT STATION TYPE/MFG S " CAPACITY ! gal # OF COMPARTMENTS cr TYPE/MFG �- CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL iolo r ft FOUNDATION �� / ft PROPERTY LINE SS0 SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ft Amount Remitted LEACH LINES ❑ LEACHING CHAMBERS # OF LINES�L LENGTH OF LINES �5� v ft ) I DISTANCE TO NEAREST WELL 100'r ft / FOUNDATION -[ 0 ` ft PROPERTY LINE 30 A 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 r DISTANCE TO NEAREST WELL ft 3 WIDTH FOUNDATION ft PROPERTY LINE L ft DEPTH �J`rr ft ft SEEPAGE PITS NUMBER DISTANCE TO"'NEAREST WELL �5-O ft FOUNDATION ®' ft PROPERTY LINE -70' 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. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIIONS - PLEASE CALL (209) 953-7697 SIGNED %�,. � 1 -2 -TITLE �t'l/h/4— DATE ri - 57— dd Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS tJeVJ Pr �er pro�r/✓►n Po��'G4fna�o PE Code SC INFO Received By heck # ash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# a 1 ) I 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 T H N