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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 PER �M IT (:ALL LUy `4D.f-10`41 FOR INSPECTIONS / CXPIRES "I TEAR FROM UATE ISSUE JOB ADDRESS - / A 3 ,) S CITY/ZIP CROSS STREET flop So.AeeP1�,, APN —Z �� 03 V PARCEL SIZE OWNER NAME Ti�+,� ' ^ �eS PHONE OWNER ADDRESS Sc/ ► ` l CITY/STATE/ZIP �^ CONTRACTOR�, PHONE��O�T�/%/�J/%�/e CONTRACTOR ADDRESS I y ( / L/- % ��y' �`� V — A CITY/STATE/ZIP LICENSE 1111C-42 110C-36 OTHER s�1sj NUMBER / 1 EXPIRATION DATE WATER TABLE DEPTH: Ho ' � � ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # I BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION I REPAIRIADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE ❑ REPLACEMENT --7r ❑ OUT -OF -SERVICE SEPTIC SYSTEM Lr DESTRUCTION 5 r p i i( INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL y ❑ OTHER NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: 1 NUMBER OF EMPLOYEES: ® SEPTIC TANK TYPE/MFG ` �Y L R CAPACITY U J gal # OF COMPARTMENTS 2 V ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION 20 ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS Date Permit/ Invoice # Re nest # Permit ID# # OF LINES 2 $300 LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ® FILTER BED WIDTH /_S ft LENGTH yC ft DEPTH Z ��`'b ft DISTANCE TO NEAREST WELL ft FOUNDATION 10-t ft PROPERTY LINE S' } 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 ft ❑ 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. Application Application Accepted By _ Final Inspection By Character of Soil to Depth COMMENTSt, ' e �i � �E'r 6F?r�. ✓ �- z— k 3 Ft:— i /-/AP.PD Er' DEPARTMENT USE ONLY _ Date Area 5 iG Employee ID# Date ❑ SPECIAL PERMIT - Approved by Pit/Sump Soil Character: A51;1 . , -11N �) A< 2 - )Pr J-11- 0 PE Sc Code INFO Received Check#/ Amount ljy Cash RemittedService Date Permit/ Invoice # Re nest # Permit ID# a a o i 2 $300 i5 �. �D 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 11