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PERMIT ONSITE WASTEWATER TREATMENT SYSTEM PERMIT EXPIRED SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT GALL ZUY Yb3-/6'J/ FOR INSPECTIONS X Y I=XPIRES 7 YEAR FROM UATE ISSUE JOB ADDRESS �` ? (s r V.��. G\ c P ,ti CITY/ZIP o `" , '' j �. CROSS STREET �� r M \ C� `� APN �� a6O — I T l./ PARCEL SIZE OWNER NAME r l L /� c: A q S'_ C'Sr NUMBER OF LIVING UNITS: PHONE Z NUMBER OF EMPLOYEES: I SEPTIC TANK IV (�L�-7- OWNER ADDRESS D% ISC (� 1� `' `�� `J CITY/STATE/ZIP ' 4 C U �/ r`4 ice! CONTRACTOR T/ DISTANCE TO NEAREST: PHONE T C7. � L I ` L 2/7_2-7 CONTRACTOR ADDRESS LICENSE ❑FIC -42 1111C-36 OTHER CITY/STATE/ZIP NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: i NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION -j -f 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 DISTANCE TO NEAREST: WELL PEI MITUNDATION ft PROPERTY LINE ft ❑— LIFT STATION SIZE TYPE OF PUMPArpj�G TX PLANT KKt V C3 SAND OIL SEPARATOR (ENCLOSED SYSTEM) 13 LEACH LINES -- -- LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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. MINIMU 48 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-76 7 �� ��sz� SIGNED i G TITLE Lx"��` DATE %/9 Character of Soil to Depthof 3 COMMENTS kJUVU Soil Character: PE SC Received Check#/ Amount Date Permit/ I Permit ID# Code INFO B ash Remitted Service -Request # 2 7 0o 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 r