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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 NUN-MEFUNDABLE FERMI] JOB ADDRESS �//t--)S / _jam CROSS STREET / I- n G OWNER NAM CALL (ZU&) V0J-[0V1 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE] ETa1- APN CITY//ZIP CX ) a 1 7 0G / k PARCEL SIZE PHONE S/o - 371-ly/3 OWNER ADDRESS SC'J 11! CITY/STATE/ZIP �� CONTRACTOR PHONE _ _�� 0 /7 CONTRACTOR ADDRESS ��CITY/STATE/ZIP LICENSE ❑�-42 ❑❑C-36 OTHER NUMBER_ L� �� EXPIRATION DATE TJ�1/�'% WATER TABLE DEPTH: b' �� ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION l ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIV/p_ a REPLACEMENT Ifl11 � ' 1 4 I ^' ' El OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION S c L IC VI INSTALLATION WILL SERVE: 2�, RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: % NUMBER OF BEDROOMS: 4 NUMBER OF EMPLOYEES: I SEPTIC TANK TYPE/MFG yC� CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST WELL DISTANCE TO NEAREST: WELL S _ ft FOUNDATION ft PROPERTY LINE 7S ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) r� LEACH LINES ❑ LEACHING CHAMBERS # OF LINES _- LENGTH OF LINES %cam ft Y) CS: 6? 066nd ft DEPTH ft A ■ DISTANCE TO NEAREST WELL ljL% _ ft FOUNDATION 7S ft PROPERTY LINE ft FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL MOUNDED WIDTH ft LENGTH DISTANCE TO NEAREST WELL SUMPS WIDTH ft LENGTH DISTANCE TO NEAREST WELL DISPOSAL PONDS WIDTH ft LENGTH DISTANCE TO NEAREST WELL SEEPAGE PITS NUMBER WIDTH_ DISTANCE TO NEAREST WELL ft / FOUNDATION Employee ]D# ft PROPERTY LINE ft Application Accepted By 11" aid ft DEPTH ft ft FOUNDATION ft PROPERTY LINE ft - Approved by Character of Soil to Depth of 3 Ft: ft DEPTH ft ft FOUNDATION ft PROPERTY LINE ft Y) CS: 6? 066nd ft DEPTH ft ft FOUNDATION -ft PROPERTY LINE ft -ft DEPTH ft 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. PE Code DEPARTMENT, USE ONLY ��'L� Dated Area 5 Employee ]D# Invoice # Application Accepted By 11" aid 1s" Final Inspection By Date 3 Z ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS 1 y C-AfefY14,(Ie0C-r it N-0 aper rl,)s on Y) CS: 6? 066nd 5 -DI -lam PE Code SC Receive INFO A J5Y Check#/ Amount Date Permit/ Cash RemittedService Request Invoice # Permit ID# aid 1s" 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18