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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 NUN-1[EPUNDABLE PERMIT GALL (LU.9) 903 -/ti / FOR INSPECTIONS LXPIRES 1 YEAR FROM DATE ISSUE JOB ADDRESS 16 9V A1,54 l% Q! CITY/ZIP © Lid 1) 0-7 j % - I, CROSS STREET P/ APN l a n?0 30 D � ❑ FILTER BED ^� PARCEL SIZE / aC )� �577Gl�� DEPTH ft /'J1- OWNER NAME / WELL PHONE-9 Z� l3 - y��) / �rl�Gt//VU OWNER ADDRESS Lets �/I.s ct CITY/STATE/ZIP 4pn J � I n7la CONTRACTOR ��/L �t'Lft JO11nyf /S�2d j�� / %(// ��)//'�(� PHONE DISTANCE TO NEAREST �j CONTRACTOR ADDRESS /`T� N CITY/STATE/ZIP ❑ SUMPS WIDTH LICENSE 1111C-42 ❑❑C-36 OTHER NUMBER - 03 EXPIRATION DATE__ f '•r'S l� �Zi WATER TABLE DEPTH: CO -70 ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # I BUILDING PERMIT # 10 ) (7 LJy LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE ❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: [� NUMBER OF EMPLOYEES: R SEPTIC TANK TYPE/MFG�j CAPACITY ��c,Vi�% gal #OF COMPARTMENTS_ ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL Ili(/ ft FOUNDATION ft PROPERTY LINE 7 n -�- ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES ❑ LEACHING CHAMBERS # OF LINES Z LENGTH OF LINES S S l ft Lid 1) 0-7 DISTANCE TO NEAREST WELL .1120 77 ft FOUNDATION /�LZ ft PROPERTY LINE j ) ft ❑ FILTER BED WIDTH ft LENGTH _ It 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 NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER WIDTH�3 ft DEPTH lei 5 It DISTANCE TO NEAREST WELL % ft FOUNDATION 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. Final Inspection By/ Date ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS N PW S F12. T� a✓ �. G PE SC Code INFO Received Check#/ B Cash Amount RemitteService Request # Invoice # Permit ID# Lid 1) 0-7 s S aPermit/ 030 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18