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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-KEFUNDABLE PERMIT , 1 n GALL (ZUY) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE L -i JOB ADDRESS 15351 Pt= h EP CITYIZIP CROSS STREET Greek APN O 1 U �� PARCEL SIZE `�v ✓ OWNER NAME ✓b Qir ma h I C4 `� I �e4 u l PHONE OWNERADDRESS Sc►mf CITY/STATE/ZIP CONTRA -TOR CDAJTR�ICTOFi ACf9�SS LICENSE 11❑C-42 1111C-36 PHONE CITY/STATE/ZIP NUMBER EXPIRATION 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 /ALTERNATIVY�E ❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION '. 1. NIX INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: 1 ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ MOUNDED DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS Received C Amount ate Permit/ Bx Cas Remitted Service Re ues # DISTANCE TO NEAREST ❑ FILTER BED WIDTH ft DISTANCE TO NEAREST ❑ MOUNDED WIDTH DISTANCE TO NEAREST ❑ SUMPS WIDTH ft DISTANCE TO NEAREST L1 DISPOSAL PONDS WIDTH DISTANCE TO NEAREST Ll SEEPAGE PITS NUMBER ft DISTANCE TO NEAREST WELL WELL WELL WELL WELL WELL SC INFO Received C Amount ate Permit/ Bx Cas Remitted Service Re ues # # OF LINES a�-7s ft FOUNDATION ft LENGTH ft FOUNDATION ft LENGTH ft FOUNDATION ft LENGTH ft FOUNDATION ft LENGTH ft FOUNDATION WIDTH ft FOUNDATION LENGTH OF LINES ft ft PROPERTY LINE ft ft DEPTH ft ft PROPERTY LINE ft ft DEPTH ft ft PROPERTY LINE ft ft DEPTH ft ft PROPERTY LINE ft ft DEPTH ft ft PROPERTY LINE ft _ft DEPTH ft ft PROPERTY LINE ft I HEREBY CERTIFY THAT 1 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. IV111VI lUIV 4 d7(JUK 1VL C /VV I A-0 ITC U1rTC" rVIT IIYJrCIr 11wma - rLCMJC IrMLL GVJ Ji7J-I VJI SIGNED C .�I�� TITLE C.jT�% Z. k� DATE DEPARTMENT USE ONLY u Application Accepted Date S'd Area 1 Employee ID#� Final In By Yl ' Date -S77 ` ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS SPb}!c �e4Yl k Mal/ ha-Yc 6eeY7 f.ep7ove'r."I Iln IcigG] were c'b re i o (oc'e-q e - IT C ) . PE Code SC INFO Received C Amount ate Permit/ Bx Cas Remitted Service Re ues # Invoice # Permit ID# a�-7s b 41 S 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/16