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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-KEFUNDABL/E P/ERMIT GALL ZU9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED J( L JOB ADDRESS 71- _ 0. ST R -T• z6 CITY/ZIP �j-ac�cTon/ 9s2lr CROSS STREET 13EECHFlZ APNN D - D7PAARCCEL/SIZE Q� Ba OWNER NAME 2 tlLL e^ IG1'7-1� 1�I �1 le-, PHONE OW / ^k4l -Sq3� %7 OWNER ADDRESS 1/4 57w. � ,4 Of 5o Al ( 3--1-3/7 r i'K I� 4 D / CITY/STATE/ZIP pr 7-0 C W-rO &4 OA 15'2-* �gj—.- /`fG� ��)I't/. Ll�L7 PHONE �tJT-��' �GSp� X CONTRACTOR CONTRACTOR ADDRESS r v • O , L30 X ^3 [ �7 2!!� CITY/STATE/ZIP QC LICENSE ❑CIC -42 EIEC -36 OTHER 12C� NUMBER_EXPIRATION DATE W TER TABLE DEPTH: �y 7 ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ;1 NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED /ALTERNATIVE .. REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM 1 1 DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG CAPACITY CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION _ ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT LEACH LINES LEACHING CHAMBERS FOUNDATION DISTANCE TO NEAREST WELL FILTER BED WIDTH ft FOUNDATION DISTANCE TO NEAREST WELL MOUNDED WIDTH ft FOUNDATION DISTANCE TO NEAREST WELL SUMPS WIDTH ft FOUNDATION DISTANCE TO NEAREST WELL DISPOSAL PONDS WIDTH ft DISTANCE TO NEAREST WELL SEEPAGE PITS NUMBER DISTANCE TO NEAREST WELL # OF LINES gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ft FOUNDATION WIDTH ft ft FOUNDATION LENGTH OF LINES _ ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE I HEREBY CERTI ]SHAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, / 11-1 STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. Irurvnr/ III •fv nuvn/va.c Ivvin.c r-vrc IIYJrCV IIV/vJ - r-1.-GnJC a.ncc cv; SIGNED iMAMAZ TITLE 0-(I///- "lIMALE2 DATE H m a SG, DEPARTMENT USE ONLY Application Accepted By L- Date q1L.,31WArea Gc Employee ID# Final Inspection By Date Z ❑ SPECIAL PERMIT -Approved by Character of Soil to Dept"f- 3 Ft: Pit/Sump Soil Character: COMMENTS 57JVd,tl AI ) &-t- ut�t�, Ste) o i �z�&Pati ' ' .r,�?"6 wituI t k PE Code ft FOUNDATION LENGTH Permit/ Service Request # ft Permit ID# ft FOUNDATION LENGTH ft ft FOUNDATION LENGTH ft ft FOUNDATION LENGTH ft ft FOUNDATION WIDTH ft ft FOUNDATION LENGTH OF LINES _ ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE I HEREBY CERTI ]SHAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, / 11-1 STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. Irurvnr/ III •fv nuvn/va.c Ivvin.c r-vrc IIYJrCV IIV/vJ - r-1.-GnJC a.ncc cv; SIGNED iMAMAZ TITLE 0-(I///- "lIMALE2 DATE H m a SG, DEPARTMENT USE ONLY Application Accepted By L- Date q1L.,31WArea Gc Employee ID# Final Inspection By Date Z ❑ SPECIAL PERMIT -Approved by Character of Soil to Dept"f- 3 Ft: Pit/Sump Soil Character: COMMENTS 57JVd,tl AI ) &-t- ut�t�, Ste) o i �z�&Pati ' ' .r,�?"6 wituI t k PE Code SC ReceivedCheck#I INFO B Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# q)a') -a � 3J4-1 -5*1 15 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18