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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 CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 1 'f JOB ADDRESS -11' [_r �7�-�'" - CROSS STREET LLEWA%X-�b CITY21P_ ( `1 JO+f l-_- APN Z'fg - 230 - 09 / PARCEL SIZES OWNER NAME DO UGTO (L2ES PHONE `SI d, 2-6 m - OWNER ADDRESS hY�t CITY/STATEJZIP CONTRACTOR LIVE, rOP� GTI CCtEVj90tjmEN76I- PHONE 44 CONTRACTOR ADDRESS 0-1 W . (.)P( %- ST- CITY/STATE/ZIP LICENSE . C-42 iJ C36 OTHER Ce-(- NUMBER EXPIRATION DATE WATER TABLE DEPTH: fl GEOGRAPHICAL INFORMATION: Coordinates X Y ;4 PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE J COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS _ ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL fl FOUNDATION It PROPERTY LINE f1 ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS #OF LINES Permit ID# LENGTH OF LINES It - DISTANCE TO NEAREST WELL R FOUNDATION It PROPERTY LINE It ❑ FILTER BED WIDTH It LENGTH R DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH It LENGTH ft DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION fl PROPERTY LINE It ❑ SUMPS WIDTH ft LENGTH It DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION fi PROPERTY LINE It ❑ 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 SANJOAQUIN COUNTY. % DEPARTMENT US L ONY , l ! Application Accepted By 1 L, Date JArea 5 C Employee ID# Final Inspection By '; - +7i "�Zl Date ?Zl �- 1— SPECIAL PERMIT - Approved by _ Character of Soil to Depth of 3 Ft: ________ Pit/Sump Sail Character: COMMENTS lire r 1I c PE SC Code INFO Received Check By ash Amount Date Permit/ Invoice # Remitted Service Request# Permit ID# Lw;' 5p3 - two Q �a 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 414/18