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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 PERMIT CALL 209 953-7697 FOR INSPECTIONS d EXPIRES 1 YEAR FROM DATE ISSUED JOBADDRESS 27,91 CIIT7YIZIP �! (]( �%1, CA �S/pCCcp CROSS STREET A/ CC,17,5S OD. APN r Xf'j) (�y t q PARCEL SIZE 1� OWNER NAME �� PHONE OWNER ADDRESS P•Ofi5s-Z'770 CITY/STATE/ZIP Sein [oo Cisc o CONTRACTOR 1;EF_GC1 PHONE /� C CONTRACTOR ADDRESS �LG ��/�f�{�� 9f� j CITY/STATE/ZIP (� /�rCX}1M •U A LICENSE ❑❑C-42 ❑❑C-36 OTHER C-_ r� v NUMBER rV / EXPIRATION DATE 6Z,5Dlf� WATER TABLE DEPTH: I / ' ^ �/ FN r ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # 01091'764 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 7) f NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: "1 V CC SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG CAPACITY > UGC) gal #OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST ❑ DISPOSAL PONDS WIDTH DISTANCE TO NEAREST WELL ft FOUNDATION ft LENGTH WELL ft FOUNDATION ft PROPERTY LINE ft ft DEPTH ft ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft I HEREBY CERTIFY TH '1 VPREPARED 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 TITLE 0 kcl Jla.i - Pr DATE 20�2 DEPARTMENT USE ONLY Application Accepted By,, Date Area `d Employee ID# f� Final Inspection By f 44 Date ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS Nei S-lroOtIre Aran fe pa 14. ) , filo PE Sc Received Check#/ Amount Code INFO B Cash Remitted Date Permit/ Invoice # Permit ID# Service Request # DISTANCE TO NEAREST: WELL a D ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft 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 lAD ft LENGTH 40 ft DEPTH & / Jr� ft DISTANCE TO NEAREST WELL. I t0 ft FOUNDATION t ft PROPERTY LINE InZ ] ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST ❑ DISPOSAL PONDS WIDTH DISTANCE TO NEAREST WELL ft FOUNDATION ft LENGTH WELL ft FOUNDATION ft PROPERTY LINE ft ft DEPTH ft ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft I HEREBY CERTIFY TH '1 VPREPARED 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 TITLE 0 kcl Jla.i - Pr DATE 20�2 DEPARTMENT USE ONLY Application Accepted By,, Date Area `d Employee ID# f� Final Inspection By f 44 Date ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS Nei S-lroOtIre Aran fe pa 14. ) , filo PE Sc Received Check#/ Amount Code INFO B Cash Remitted Date Permit/ Invoice # Permit ID# Service Request # 2 S ►2 0D $y ORL- 42-01 //� _;� 1 �"ID I �/1T ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 ` • ''�' L%I D