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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-KEFUNDABLE PER (MIT (:ALL LUY Y03-10YI FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE JOB ADDRESS `7 1 " ^ In %� CITY/ZIP �`%��iL, /Z2 CROSS STREET VC*7 S05 I e Vii AP (5(71 / U J PARCEL SIZE A OWNER NAME , i� AJ C� Z_ C PHONE OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR G `� ' -U C" PHONE �? + 5 J — 1 L%J -? I CONTRACTOR ADDRESS t/ w Cl✓ ��1 CITY/STATE/ZIP�,.J� LICENSE [][C-42 ❑'.=1C-36 OTHER G' NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: i. NEW INSTALLATION /�REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE P REPLACEMENT �/ Y�OUT-0F-SERVICE SEPTIC SYSTEM Ir DESTRUCTION 7'9 N INSTALLATION WILL SERVE: Q RESIDENCE [I COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: - l A NUMBER OF BEDROOMS: �' NUMBER OF EMPLOYEES: ® SEPTIC TANK ❑ GREASETRAP ❑ LIFT STATION TYPE/MFG CAPACITY rG TYPE/MFG ` CAPACITY DISTANCE TO NEAREST: WELL J� ft FOUNDATION SIZE _ TYPE OF PUMP ❑ PKG TX PLANT ❑ LEACH LINES C LEACHING CHAMBERS Received By ec ash DISTANCE TO NEAREST WELL Invoice # ❑ FILTER BED WIDTH ft LENGTH ( DISTANCE TO NEAREST WELL ❑ MOUNDED WIDTH ft LENGTH DISTANCE TO NEAREST WELL ❑ SUMPS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ❑ DISPOSAL PONDS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ❑ SEEPAGE PITS NUMBER WIDTH _ DISTANCE TO NEAREST WELL gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) # OF LINES ft FOUNDATION ft ft FOUNDATION ft ft FOUNDATION ft ft FOUNDATION ft ft FOUNDATION 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 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. ft DEPARTMENT USE ONLY Application Accepted 141sic —UG- Date�// �� Area S Employee ID#_ Final Inspection By,¢l,$}s, Li,`L_ Date (� �3/%�, ❑ SP CIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS lin��eterwli.�► , �iHI' _Imk- ph Iv, PE Code SC INFO Received By ec ash Amount Remitted Date PermlU Service Request # Invoice # Permit ID# i-I)o t )1s ( 3( cDo 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18