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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-KEFUNDABLE I ERMIT JOB ADDRESS CROSS STREET OWNER NAME OWNER ADDRESS t:ALL (ZUY) y53 -/6y/ FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE CITY/ZIP --7 C-OLf AP 1► PARCEL SIZE / HONE �/J" /®�-/ / FI— 0 CITY/STATE/ZIP �14--4 ( � C71-7-, CONTRACTOR/�'�i�j�i�'1� /`Q�%I (/.�/l�Y� �I'�.[ PHONE yOf'' �J�-7 l CONTRACTOR ADDRESS / D I �Ty�Y n CITY/STATE/ZIP <�%G�'�C� A 614 'f J v 0 LICENSE I C-42 ❑LIC -36 OTHER NUMBER n? 1/ (.EXPIRATION DATE O7 — J� WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION L 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 CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS Permit ID# DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES 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 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION 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. MINI VANCE NOTICE REQUIRED FOR INSPECTIO S - PLEASE CALL 209 953-7697 SIGNED J //� �/ TITLE r - DATE ?iZ ZQLZ ft ft ft ft ft ft ft ft ft ft ft ft ft JJ DEPARTMENT USE ONLY In Application Accepted By L�� !_ Date d1d,2Lda Area a S'}JLkfm Employee ID# Final Inspection By `Jj%'~ Date 7 eZ ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of Ft: Pit/Sump Soil Character: COMMENTS COMMENTS 54614P/- Y "D y; I e o k (s hots 1-122&y b,p lrl PE Code SC INFO Received By Check ash Amount RemittedService Request # Invoice # Permit ID# I 07S - 415 aPermit/ 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 r