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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 PERMI'TJ CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR , FROM DATE ISSUED JOBADDRESS `'i�I�S G��I�h i/T/��I�(�%�T CITY/ZIP -1� RCY��-�tOn ? b Iv �) CROSS STREET ' L�� ^ APN' I ( PARRC�EL�SIZE 2v�'�j OWNER NAME 1 \Q� �� U�C��i PHONE\ \ 1(.IIZl h Cfl �FJ2 \`J OWNER ADDRESS L111�J � � rC\� CITY/STATE/ZIP S\(pr-\oVocz CONTRACTOR I I -F PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑ C-42 ❑ C-36 OTHER NUMBER EXPIRATION DA WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION / ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM Y DESTRUCTION S.(� ��-�� FINSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ❑ OTHER NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS Date I ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DD [ DISTANCE TO NEAREST: WELL 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 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. 48 HOUR ADV NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953--7}6971 ^� MINIMUM SIGNED TITLE_-' m DATE C� I dt� f OLQ aLo' J''DTPARTMENT USE ONLY Application Accepted By z UV Date Final Inspection By �c, Date Character of Soil to Depth of 3 F : �76 COMME,j�ITS r0 � Area Jl = ' Employee ID#M ❑ SPECIAL PERMIT -Approved by i -F n PE Code SC INFO Received B Check#/ as Amount Remitted Date I Permit/ Service Reques�tn#( Invoice # Permit ID# DD [ n W �f 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18