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1b 4 ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 .(209) 468-3420 NON-KEFUNDABLE PERMIT JOB ADDRESS, CROSS S1 OWNER N GALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE'. CITY/ZIP G CO 1,A APN O -1 I J D�1 9 PARCEL SIZE PHONE,ze - %J � — / � OWNER ADDRESS J`<� I►')f, CITY/STATE/ZIP CONTRACTOR zf&:#A 0-� �/�� '7 J%� PHONE "ZUy /4,11 CONTRACTOR ADDRESS CITY/STATE/ZIP ❑❑ ❑❑ ,Q LICENSE C-42 C-36 OTHER / 1 NUMBER �V (/EXPIRATION DATE WATER TABLE DEPTH: I I V - a ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ 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 ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS DISTANCE TO N AREST: WELL ft FOUNDATION ft PROPERTY LINE ft LIFT STATION SIZE TYPE OF PUMP - ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) 0 LEACH LINES ❑ FILTER BED ❑ MOUNDED ❑ SUMPS ❑ LEACHING CHAMBERS DISTANCE TO NEAREST WIDTH DISTANCE TO NEAREST WIDTH DISTANCE TO NEAREST WIDTH DISTANCE TO NEAREST WELL V , "+ ft ft LENGTH # OF LINES _� LENGTH OF LINES �() ft FOUNDATION %� ft PROPERTY LINE r ft DEPTH WELL ft FOUNDATION ft LENGTH WELL ft FOUNDATION ft LENGTH WELL ft FOUNDATION ft ft ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE ft ft ft ft ft ft ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAEST WELL ft FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER OL/ WIDTH r ft DEPTH2L� _ 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. SIGNED DATE ,/ ��la %-�7 IENT IVED 6 2022 N COUNTY MENTAL J DEPARTMENTUSE ONLY Application Accepted lB/`— L/ Date I 6 a Area q -I Employee ID# 1 V; k l� Final Inspection Bye L� U� Date ZZ 11 SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS ��>> �`ln�ys fowl. �.rlstlYlC S,�S�P/3'� 'conic; in. PE SC Received Code INFO B Check#/ Amount Date Permit/ Cash Remitted Service Request # Invoice # Permit ID# Lit - 42 -01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18