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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 VERMIT UALLLU`J S/OJ-/OJ/ FOR INSPEGTIUNS tXPIKE5 "1 TEAK I•KUM LIAIE ISSUt JOB ADDRESS �+n�a 6� r 1� C� J T CITY/ZIP gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft SAND OIL SEPARATOR (ENCLOSED SYSTEM) CT ❑ LEACHING CHAMBERS - / / ^ / CROSS STREET V J LENGTH OF LINES ft APN / SIZE OWNER NAME _< r -LJ 1r� L) ma'y, " "2- T PHONE / ,PARCEL '7� � ' ow' OWNER ADDRESS —7Z V f� p A' -"IL L.JOd (-S CITY/STATE/ZIP ft LENGTH CONTRACTOR 1,'L h f iJ Vim- i�Z `r PHONE !i b q ^ 2-tO ll - 7 d 2 I CONTRACTOR ADDRESS Po OLW 12,) i CITY/STATE/ZIP L---h.Ik to �A ,* a LICENSE 110C-42 %C-36 I ',J OTHER NUMBER (:rl3P t14 EXPIRATION DATE 06 - 3C3 — ZZ - WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT## LAND USE APPLICATION ## TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION 0 ENGINEER DESIGIED /ALTERNATIVE ❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM i DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: 9 ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL SIZE TYPE OF PUMP ft CAPACITY CAPACITY FOUNDATION ❑ PKG TX PLANT ❑ gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS Remitted #OF LINES Service Request # LENGTH OF LINES ft 221 DISTANCE TO NEAREST WELL ft FOUNDATION 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 ❑ 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 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. DEPARTMENT USE NLY Application Accepted B Date �7 1 O ZZ Area Employee ID#� Final Inspection By Date (� SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENT,,,? lio� —1e) /Ri \RFK�� 5 I�� r'Xj,/dCAD ;� , x (LEC) - ( F) 5 �A � 5-� 1� �10\1\- PE SC Received Check#/ Amount Date Permit/ Invoice # Code INFO By Cash Remitted Service Request # 221 07 / S2 3 I Z2 `b rf 42-01 LQ,5 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 l7i