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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 D NUN-MtarUNUABLE PERMIT ft GEOGRAPHICAL INFORMATION: Coordinates X GALL ZVy yOJ-/Dy/ FOR INSPECTIONS LX/PJIRES 7/YdEAR FROM DATE ISSUE JOB ADDRESS '� �' �2 C�- s�' CITY/7JP 1n(l'/�jri' ' (✓/ CROSS STREET !1C! Z, REPLACEMENT " hk L� �� IS OUT-OFSERVICE SEPTIC SYSTEM APN PARCEL 512E OWNER NAME / JL^�') OTHER Yl PHONE OWNER ADDRESS SEPTIC TANK TYPE/MFG ^�1C%� -AL CAPACITY /;�CtiI GTY/STATEIZIP CONTRACTOR r�l /17/4 Ac PHONE Vej CONTRACTOR ADDRESS ft PROPERTY LINE b R CITYISTATEIZIP LICENSE YC42 CJ6 OTHER 7 NUMBER �S /"-7 EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INsTALLA'n REPAIR/ADDmoN ENGINEER DESIGNED (ALTERNATIVE !1C! Z, REPLACEMENT " hk L� �� IS OUT-OFSERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: x RESIDENCE COMMERCIAL / OTHER DISTANCE TO NEAREST NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG ^�1C%� -AL CAPACITY /;�CtiI �' gal #OFCOMPARTMENTS C;? ❑ GREASE TRAP TYPE N'IFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION e/0 ft PROPERTY LINE b R ❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT Ll SAND OIL SEPARATOR (ENCLOSED SYSTEM) - LEACHLINES LEACHING CHAMBERS i #OF LINES 3 LENGTH OF LINES J`5 ft INFO Date.Permit/ Cash Re Invoice # Permit ID# ServceR nest# !1C! Jo Fi V12,5 DISTANCE TO NEAREST WELL ZOO ft FOUNDATION It PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It SEEPAGE PITS DISTANCE TO AREST NUMBER 3 WELL WMTIfI ft FOUNDATION J 11 ft PROPERTY LINE It DEPTH S ft ft DISTANCE TO 6AREST WELL ft FOUNDATION /0' It PROPERTY UNE PC ft ! 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 H� ADVAt(g�-:N0T10E.RE0U1REQ FORS A 0 9 SIGNED �8 I,, TITLE e' l � DATE S DEPARTMENT USE O LY L Application Accepted Date ' - _Area Final Inspection By Date If i SPE Character of Soil to Depth of 3 Ft. PWSump Soil Character: COMMENTS q7 Employee ID PERMIT -Approved by k'ic / Z.' PE SC Received Check#( Amount Code INFO Date.Permit/ Cash Re Invoice # Permit ID# ServceR nest# !1C! Jo Fi V12,5 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18