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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-REFUNDABLE PERMIT f CALL 209 953-7697 FOR INSPECTIONS T�` 'EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS I.1Y)}.3�y, `• y• �L7� G6 CITYY21PSAU✓1�•TQ� 1�Z W CROSS STREET _r"�" 'Y' r S Q APN VO (- 1 10` 19 PARCELSIZE �"�• I Z-At• �j O OWNER NAME S.�VL H'ERN�tNDEZ PHONE 44tQ - �Z OWNER ADDRESS jOtorl 1:• AixA Ave. CITY/STATE/ZIP S7TGlGTBn► CT i•� �� CONTRACTOR l.1 JC O AY- G r o�yly'y� PHONE 3(o 1` 031 F- CONTRACTOR ADDRESS 4o-7 W' DAK ST' CITY/STATE/ZIP LDP I CA 15-2-140 LICENSE � C-42 I :C-36 OTHER CEV NUMBER 7-151 EXPIRATION DATE ` O ` 2q WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y )C PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION .. REPAIR/ADDITION I..i ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT .J 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 TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL It FOUNDATION ft 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 ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH It LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft ❑ SUMPS WIDTH It LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL It 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. I46 UOUR ADVAWPE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 20 953-7697 SIGNED TITLE P�J ' �2' DATE '5- I RA Y�FNT MAY J0AQU/Iy O Tl TH p��EN NT DEPARTMENTJJS ONLY Application Accepted B �� L Date S D aD Area I Employee ID# (Gt 11 k l7- Final Inspection By Date 1 /,�l 19'ZDQYSPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS 10/t4f'a ,A GO- l-ln QCC��+I. C .S•C l "DC P�lrCi PE SC Received ec Amount Date Permit/ Invoice# Permit ID# Code INFO By ash Remitted Service Request# sa3 ff 5)2()0 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18