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E ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN J AOUIN 06UNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 9$205-(209)468-3420 NO -RE 'NDA BILE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB A RESS 17 113 N ` 74 CITY21P S TU C,IGTa�.J CROSS STREET=�Ip,'�� 1,�r',y� 1 Sa APN Ok-1 (`10 9 PARCEL SIZE 2''• Z- b� / OWNERNAME SthJL FftIZNA'^JDE.'. PHONE V45' �Z j OWNER ADDRESS lO�571 L' ADA AVE. �C�K'TD r`j C A' CfTY/STATE/ZIP -/ CONTRACTOR L-IVE d/Y- &Ep6:I,jVjJ�ZmE�AL PHONE 3(✓1- 03 -e q CONTRACTOR ADDRESS 4DIt'IG 0-7 W• S.T. CITY/STATE/ZIP I-OPI CA LICENSE ❑I.'C42 00C-36 OTHER CEG NUMBER ZI S 1 EXPIRATION DATE L{ -3 O - 7-1 WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X Y 1 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: -! NEW INSTALLATION I 1 REPAIR/ADDITION I1 ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I:! DESTRUCTION 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 TYPEIMFG CAPACITY gal #OF COMPARTMENTS DISTANCETO NEAREST: WELL it FOUNDATION it PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES .: LEACHING CHAMBERS #OF LINES LENGTH OF LINES It DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE It ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH It LENGTH ft DEPTH It DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTYLINE It ❑ SUMPS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE If ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH it DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH it DISTANCE To NEAREST WELL It 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 tjOUR ADVAN E NOTICE E IRED FOR INSPECTIONS-PLEASE CALL(209),953-7697 SIGNED / TITLE Al ' m�2- DATE PEcMFNT E/V ROHM CC)UN7y TH D"P)HENT DEPARTMENT.USE ONLY 1 . Application Accepted By /— z- Date S / u Area Employee ID# Ilk Final Inspection By Date ❑ SPECIAL PERMIT-Approved by +� Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received ecAmount Date Permit/ Invoice# Permit ID# Code INFO B ash {Remitted Service Request# SSS �� 3 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18