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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 PEERMIT/ % GALL (LUY) y53-/ti5/ FOR INSPECTIONS /tXPIRES I YEAR FROM DATE ISSUEI JOB ADDRESS t5 4 tJG%/�� CITY/ZIP �/�G//�/�✓"� CROSS STREET /�/G - J APN b 03 G1 oa PARCEL SIZE / OWNER NAME x� eeLy T / �' C /c!? ► f/ PHONE 6491- 7;71k OWNER ADDRESS W)/� CITYISTATE/ZIP CONTRACTOR LcYI/XyIL (/ nt�/� e' PHONE CONTRACTOR ADDRESS J �Z/ ✓" �`� �" %�?%/� I�%� CITYISTATE/ZIP �/ LICENSE ❑)k-42 ❑❑C-36 OTHER NUMBER L�S�1USEXPIRATION DATE b-V/�11 WATER TABLE DEPTH: 3D 0 ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: Ci NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE ❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPF/MFC, CAPACITY oaf # OF COMPARTMENTS ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION SIZE TYPE OF PUMP ❑ PKG TX PLANT gal # OF COMPARTMENTS ft PROPERTY LINE f ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) 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. SIGNED Application Accept) Final Inspection By Character of Soil to COMMENTS -a DEPARTMEN Date ') Date r� TITLE DATE ' � UVJ ( o� Area Employee ID# L "�2 ❑ SPECIAL PERMIT -Approved by Pit/Sump Soil Character: PE LEACH LINES ❑ LEACHING CHAMBERS # OF LINES % LENGTH OF LINESS ft Permit/ Invoice # DISTANCE TO NEAREST WELL 1Q0 + ft FOUNDATION INFO ft PROPERTY LINE �� 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 ,,t I - SUMPS WIDTH .9 ft LENGTH %� , ft DEPTH /65 ' ft DISTANCE TO NEAREST WELL %Cho r/ ft FOUNDATION ft PROPERTY LINE / �� ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft 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. SIGNED Application Accept) Final Inspection By Character of Soil to COMMENTS -a DEPARTMEN Date ') Date r� TITLE DATE ' � UVJ ( o� Area Employee ID# L "�2 ❑ SPECIAL PERMIT -Approved by Pit/Sump Soil Character: PE SC Received Chec / Amount ate Permit/ Invoice # Permit ID# Code INFO By ash Remitted Service Request # d)o I� 3� I 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18