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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 1YUN-RthUNUAbLit rh iMl I p.,�,, (,ALy�L(GU& yDJ-/6y/ FOR INSPECTIONS ,�I tXPIRES l YEAR FROM DATE ISSUEI JOB ADDRESS SfrUD L • A'GI � f� � AD /—✓ • CITY/ZIP At—a IPO 115—ZZ-O A CROSS STREET KENNEPI CpL AP V1 ZU S PARCELSIZE 7 -CAC OWNER NAME Df°ry%D PHONE 333- 2-01199,2-01199,OWNER ADDRESS P -O- �/� C-1 q 4, CITY/STATE/ZIP itCffM?0 CA CONTRACTOR L-IJE 0M--- tt0E.NV12QNrrF-Nii`1'L PHONE 3&cj-v37S CONTRACTOR ADDRESS '"[y, w DA�c ST. CITY/STATE/ZIP ",I>( GR LICENSE CA2 ._'.. C-36 OTHER CECT NUMBER �'� EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ LEACH LINES LEACHING CHAMBERS PERC TEST # I BUILDING PERMIT # ❑ FILTER BED LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE ❑ MOUNDED WIDTH REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM i! DESTRUCTION INSTALLATION WILL SERVE: -. RESIDENCE J COMMERCIAL _ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: DISTANCE TO NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS NEAREST WELL DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES WELL DISTANCE TO NEAREST ❑ FILTER BED WIDTH LENGTH DISTANCE TO NEAREST ❑ MOUNDED WIDTH FOUNDATION ft DISTANCE TO NEAREST ❑ SUMPS WIDTH It DISTANCE TO NEAREST ❑ DISPOSAL PONDS WIDTH DISTANCE TO NEAREST ❑ SEEPAGE PITS NUMBER It LENGTH DISTANCE TO NEAREST # OF LINES LENGTH OF LINES WELL ft FOUNDAT ft LENGTH WELL It FOUNDATION ft LENGTH WELL It FOUNDATION -ft LENGTH WELL ft FOUNDATION It LENGTH WELL ft FOUNDATION WIDTH WELL ft FOUNDATION ION ft PROPERTY LINE ft DEPTH It PROPERTY LINE ft DEPTH It PROPERTY LINE ft DEPTH ft PROPERTY LINE ft DEPTH ft PROPERTY LINE ft DEPTH ft PROPERTY LINE 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. ft ft ft ft ft ft It ft ft ft ft ft DEPARTMENT U E ONLY J Application Accepted By Date 0 Area l Employee ID#� Final Inspectio:xf"Z: (/',I; Date 3 / / / 247 )-Z 7 SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received heck#/ Amountate Permit/Invoice# PermitlD# Code INFO B Remitted Ser ice Re st # WQ39� �a3 1sa �L 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 rr 0 I,