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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 ICON -REFUNDABLE PERMIT CALLL� 209 953-7697 FOR INSPECTIONS J ExPPIR/ES 1 YEAR FROM DATE ISSUE[ JOB ADDRESS , �C �/ CITY/ZIP (�(I-O /{ (1AC I_ CROSS STREET ( oco/hw �J{- /-Z A//APN O v l PARCEL SIZE �/ OWNER NAME f1A ©M I N C 6r(-6 PHONE OWNER ADDRESS L� 1 / / CITY/STATE/ZIP q CONTRACTOR 1► I1 ��1V �+ (� C �j PHONE �d /-- 3cey- s0al7 �f CONTRACTOR ADDRESS 3 / *& i�Cll'1CL/f � (V�• CITY/STATE/ZIP � � / — �/� LICENSE ❑A-42 ❑ 'C-36 OTHER NUMBER 2 6��&!!5;-EXPIRATIONDATE - 493 WATER TABLE DEPTH: 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: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFGCAPACITY TYPE/MFG CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION _ SIZE TYPE OF PUMP ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) Application Accepted By / Final Inspection By ' Character of Soil t2_Depth oft Ft: COMMENTS I i •P_ r- -1C 1L rL��t�i DEPARTMENT USE ONLY Date z0 e� Area--�3`y� Employee ID# Date ❑ SPECIAL PERMIT -Approved by Pit/SumD Soil Character: PE Code LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES /� / ft Date Permit/ Service Request # DISTANCE TO NEAREST WELL �Q' ft tt FOUNDATION 70 / 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 r WIDTH 9 ft LENGTH /a ' � ft DEPTH 46 r ft DISTANCE TO NEAREST WELL 50 ' ft FOUNDATION `('O ft PROPERTY LINE Pob 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. MINIMUM 48 HOUR ADVANCENOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 g �- e�i'l fir DATE �r�s - d C2 SIGNED TITLE Application Accepted By / Final Inspection By ' Character of Soil t2_Depth oft Ft: COMMENTS I i •P_ r- -1C 1L rL��t�i DEPARTMENT USE ONLY Date z0 e� Area--�3`y� Employee ID# Date ❑ SPECIAL PERMIT -Approved by Pit/SumD Soil Character: PE Code SC INFO Received B ,Vheck#W s Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 2 25 ZZ S12 I09SCAP5 42-01 4/14/18 I ' D -, ( > I T -I I -I",,&-1,b // ONSITE WASTEWATER TRTMNT SYSTEM PERMIT T