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V4 ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-KEFUNDABLE PERMIT IJ LEACHING CHAMBERS (:ALL ZUY 9b3-/tiY1 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS LENGTH OF LINES / G A E CITY/ZIP I Or WELL CROSS STREET (-1-4 /'I RemittedA,D /S r� 7 APN Ot7 / - a7 U - &4 SIZE �y /�D OWNERNAME (i�//yLJFJc ^L /70 r//t,�//�LC� s 7PAARCEL PHONE —ze / OWNER ADDRESS _ Io X AC �t,/Ur - 1 AP- C CITY/STATE/ZIP 6-rolIIL 1 0 , ft /R/ CONTRACTOR e (. �7 PHONE G9 �21�'//�S ❑ MOUNDED /��Y CONTRACTOR ADDRESS Y 1�Ci/� �� ! �� CITY/STATE/ZIP KLOG% Li ft LICENSE 110C-42 ❑CIC -36 OTHER NUMBER EXPIRATION DATE G ft FOUNDATION WA R TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: 11 NEW INSTALLATION REPAIR/ADDITION 1 1 ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM I I DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE E COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFTSTATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL SIZE TYPE OF PUMP CAPACITY CAPACITY ft FOUNDATION ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES IJ LEACHING CHAMBERS Received # OF LINES Amount LENGTH OF LINES # Permit ID# DISTANCE TO NEAREST WELL ft FOUNDATION RemittedA,D ft PROPERTY LINE ❑ FILTER BED WIDTH ft LENGTH 0�� ft DEPTH U5 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE I HEREBY CERTIFYIIAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, /n / /1 STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. /III/Y II III rVR IIYJrGV I IVIYJ - r"LGM JC 6rMLL GV: SIGNED TITLE CIV/L E/VG,//1�F�2 DATE ) DEPARTMENT UAE ONLY Application Accepted By —,,"Y��L� Date %$/ Area I �G Employee ID# F{c?V1 k 17 Final Inspection By &'u s Cp Date �/ j� /Z Z C SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: PiUSump Soil Character: COMMENTS -JTz,/-1L`.. t> 't -/T. 'lsb 1i L. (1=u �i).ril() 1- IwIkki,%/,55)' 1-7-5, /1', ft ft ft ft ft ft ft ft ft ft ft ft PE SC Received heck Amount Permit]Code # Permit ID# INFO B Cash RemittedA,D Service Re uest #Invoice Llaaa sa3 0�� Z2 ` '1 U5 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18