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C ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT GALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE JOB ADDRESS I wsc p;--> �-yJi c)'P 0 ./ [iv CITY/ZIP GC'<I►'�1 f Le7f— CROSS STREET �� %s`S((��%� APN :Ja�9-�so �� PARCEL SIZE p% OWNER NAME '(CIv�Oi��/ PHONE OWNER ADDRESS I CITY/STATE/Z_IP CONTRACTOR C-'CPHONE 5Z61T CONTRACTOR ADDRESS 374& /yx'440-1 1�Ilk /9�' CITY/STATE/ZIP LICENSE ❑X-42 ❑3C-36 OTHER NUMBER 596 EXPIRATION DATE WATER TABLE DEPTH: 12-0 ft GEOGRAPHICAL INFORMATION: ❑ PERC TEST # BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION [7 REPAIR/ADC Coordinates X Y LAND USE APPLICATION # )N ❑ ENGINEER DESIGNED G REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIALi ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: (-J / NUMBER OF EMPLOYEES: TERNATIVE I"l SEPTIC TANK TYPE/MFG (,�nCr-ems/ P� CAPACITY /L2Qr) gal #OF COMPARTMENTS 72- ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS FOUNDATION JCI DISTANCE TO NEAREST: WELL ;�bC I ft FOUNDATION 'f ft PROPERTY LINE 60 ff ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) Application Accepted By Final Inspection By Character of Soil to Depth of 3 COMMENTS Alowj EPA RTMENT USE QNLY C Date '1 2( Area 1 ( Employee ID#' Z Date 2 v ❑ SPECIAL PERMIT - Approved by Pit/ ump Soil Character: PE Code SC INFO (3/ 5� ' 1 LEACH LINES CI LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft t DISTANCE TO NEAREST WELL �Qf� ft FOUNDATION JCI ft PROPERTY LINE 60 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 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 AREST WELL J� ft SEEPAGE PITS NUMBER WIDTH�]`� FOUNDATION ft ft PROPERTY LINE ft DEPTH �/ ft DISTANCE TO)ITEAREST 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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE t !! — DATE Application Accepted By Final Inspection By Character of Soil to Depth of 3 COMMENTS Alowj EPA RTMENT USE QNLY C Date '1 2( Area 1 ( Employee ID#' Z Date 2 v ❑ SPECIAL PERMIT - Approved by Pit/ ump Soil Character: PE Code SC INFO Received B Chec Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# Z/ i 2 5� 11 7C SV'Z 0-0,9LG;32 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 rr